Careone at New Milford

Inspectors wroteBased on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to provide sufficient nursing staff to ensure staff signed the resident's medical records as medications and treatments provided for 1 of 35 residents (Resident #47). This deficient practice was evidenced by the following: On 6/24/26 at 9:50 AM, the surveyor observed Resident #47 lying in bed with enteral feeding in place. On 6/25/26 at 9:15 AM, the surveyor reviewed the medical record for Resident #47. A review of the admission Record or face sheet (an admission summary) revealed diagnoses which included, but were not limited to; late effects of cerebral infarction, aphasia following cerebral infarction, dysphagia, dementia, epilepsy, hypertension, and gastrostomy status. [...]

Inspectors wroteComplaint #: 2712392, 2983958 Based on interviews and review of pertinent facility documents, it was determined that the facility failed to implement their abuse policy to ensure a criminal background check (CBC) was completed prior to hire for one of three staff (Business Office Manager) reviewed for CBCs. This deficient practice was evidenced by the following:On 05/15/2026, the surveyor reviewed three employee files which revealed the following: Review of the employee file for the Business Office Manager (BOM) revealed a date of hire (DOH) of 04/22/2013. Further review of the BOM's employee file revealed a CBC dated 05/07/2026. An interview was conducted with the Licensed Nursing Home Administrator (LNHA) on 05/15/2026 at 3:55 PM. The LNHA stated that the facility's BOM was hired in 2013 and transferred to the facility from another facility in the network. [...]

Inspectors wroteComplaint # NJ: #166361; #173486 Based on interview, record review, and review of other facility documentation, it was determined that the facility failed to adequately assess a cognitively impaired resident, with a history of elopement as an elopement risk, and implement interventions to prevent the resident from exiting a secured unit, subsequently the facility, which resulted in the resident eloping on 7/29/23. This deficient practice was identified for 1 of 1 resident reviewed for elopement (Resident #123). On 7/29/23, Resident #123 who was cognitively impaired and ambulated independently with a history of elopement, eloped from the facility and was last seen by staff at 5:30 PM, in the television (TV) room. At 6:00 PM, the Registered Nurse (RN #1) could not locate the resident, and a code gray was called, and the facility began to search for the resident. [...]

Inspectors wroteBased on observation, interview, and review of other facility documentation, the facility failed to ensure the facility was maintained in a safe, clean, and homelike environment. This deficient practice was identified for 3 of 32 residents, (Residents #41, #56, and #107), observed during environmental tour and medication administration. This deficient practice was evidenced by the following: 1. During the initial tour of the 2nd-floor unit on 2/24/2025 at 10:49 AM, Surveyor #1 (S#1) observed Resident #107's room with no privacy curtain and the ankle-foot orthosis (AFO, is a hard brace worn on the lower leg that improves overall walking safety and efficiency for people with certain medical conditions) in the windowsill. [...]

Inspectors wroteComplaint NJ#166361 Complaint NJ#173486 Based on interview, record review, and review of other facility documentation, it was determined that the facility failed to report to the New Jersey Department of Health (NJDOH) and the Ombudsman's office when a resident eloped from the facility in a timely manner and submit the facility's investigation within 5 days for 1 of 1 resident reviewed for elopement (Resident #123). This deficient practice was evidenced by the following: Refer to F689 On 2/25/25 at 8:43 AM, the surveyor reviewed the electronic medical record (EMR) of Resident #123. A review of the admission Record (an admission summary) reflected that the resident was admitted to the facility that included diagnoses but were not limited to; unspecified dementia, low back pain, and chronic pain related to neoplasm (abnormal growth of tissue). [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to accurately code the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, in accordance with federal guidelines for 2 of 35 residents (Resident #72 and #110), reviewed for MDS accuracy. This deficient practice was evidenced by the following: Reference: A review of the latest version of the MDS 3.0 Manual (updated October 2024), Chapter 3-page K-4, under steps for assessment revealed: This item compares the resident's weight in the current observation period with their weight at two snapshots in time: -At a point closest to 30-days preceding the current weight. -At a point closest to 180-days preceding the current weight. 1. On 3/3/25 at 9:17 AM, the surveyor reviewed the electronic medical record (EMR) of Resident #72. A review of the admission Record (AR; [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to revise the comprehensive care plans (CP) for 1 of 35 residents reviewed (Resident #63). This deficient practice was evidenced by the following: On 2/24/25 at 10:59 AM, the surveyor observed Resident # 63 was seated in a wheelchair (w/c) in front of their room, repeatedly stated, why, I am here, come here. The resident was able to self propel their w/c in short distance. The surveyor reviewed Resident #63's medical records and revealed: A review of the admission Record (an admission summary) reflected that Resident #63 was admitted to the facility with medical diagnoses which included but not limited to; [...]

Inspectors wroteREPEAT DEFICIENCY Based on observation, interview, record review, and review of other pertinent facility provided documentation, the facility failed to ensure that the recommendations of the Consultant were followed and reviewed by the Primary Care Physician for 1 of 6 residents, (Resident #32), reviewed for use of psychoactive medications according to the standard of clinical practice. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, by failing to; a.) ensure that the fall and pain evaluations were done as part of fall investigation, b.) care plan (CP) intervention was followed, and c.) CP intervention was in place for each fall and revised to reflect current condition of the resident. This deficient practice was identified for 1 of 5 residents, (Resident #107), reviewed for accidents and was evidenced by the following: Reference: New Jersey Statutes, Annotated Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the state of New Jersey states: [...]

Inspectors wroteComplaint NJ #176146 Based on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to; a.) determine the cause, implement a new intervention, and start treatment to prevent further pressure injury/pressure ulcer (PI/PU) for a facility acquired PI/PU for 1 of 2 residents reviewed for PU, (Resident #102), b.) follow the recommendations of the wound care consultant physician for 1 of 2 residents reviewed for PU, (Resident #102), c.) follow a physician order for Braden Scale assessment for 2 of 2 residents reviewed for PU, (Resident #102 and #302), and d.) clarify multiple physician orders for 1 of 2 residents reviewed for PU, (Resident #302). This deficient practice was evidenced by the following: 1. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to provide care and services in accordance with professional standards by adjusting medication times of administration to accommodate for dialysis scheduled times. This deficient practice was identified for 1 of 2 residents, (Resident #22), reviewed for dialysis services and was evidenced by the following: On 2/24/25 at 11:00 AM, the surveyor observed the Resident #22 lying in bed, who stated, I have dialysis on Tuesday, Thursday, and Saturday. I get picked up around 11:00 AM and I get back around 5:00 PM. A review of the admission Record (an admission summary) revealed diagnoses which included but not limited to end stage renal disease (ESRD-kidneys have permanently lost their ability to function adequately) and dependence on renal dialysis (procedure which removes wastes and excess fluid from the blood). [...]

Inspectors wroteBased on interviews and review of other facility documentation, the facility failed to ensure that the physician must review the resident's total program of care and date progress notes at each visit. This deficient practice was identified for 1 of 35 residents, (Resident #63), reviewed for physician services. This deficient practice was evidenced by the following: On 2/24/25 at 10:59 AM, the surveyor observed Resident #63 was seated in a wheelchair in front of their room, repeatedly stated, why, I am here, come here. The surveyor reviewed Resident #63's medical records and revealed: A review of the admission Record (an admission summary) reflected that Resident #63 was admitted to the facility with medical diagnoses which included but not limited to; [...]

Inspectors wroteCOMPLAINT #NJ175735 Based on observation, interview, record review, and review of other pertinent documents, it was determined that the facility failed to provide or obtain routine medications in order to meet the needs of each resident for 3 of 35 residents reviewed (Residents #5, #32, and #352). This deficient practice was evidenced by the following: 1. On 2/26/25 at 7:57 AM, the surveyor observed Licensed Practical Nurse #1 (LPN#1) prepared and administered medications (meds) of Resident #5 (from the 2nd floor unit). LPN#1 informed the surveyor that there was no available Florastor (used as a probiotic, or friendly bacteria, to prevent the growth of harmful bacteria in the stomach and intestines) 250 mg (milligrams) in the medicine (med) cart. LPN#1 stated that she would check later in the back up machine for Florastor. LPN#1 did two residents for med pass observation. [...]

Inspectors wroteBased on observation, interview, review of the medical records and other facility documentation, it was determined that the facility failed to provide adequate monitoring for the use of psychoactive medications (meds). This deficient practice was identified for 2 of 6 residents reviewed for psychoactive meds used (Residents #32 and #63), and was evidenced by the following: 1. On 2/24/25 at 11:06 AM, the surveyor observed Resident # 32 seated in a wheelchair (w/c) in front of the elevator with other residents. The resident afterward was propelled by Recreation Aide #1 (RA#1), who informed the surveyor that the resident will be going down for lunch. The surveyor reviewed the medical records for Resident #32. A review of the admission Record (AR, an admission summary) reflected that Resident #32 was admitted to the facility with the diagnoses which included but not limited to; [...]

Inspectors wroteBased on observation, interview, and review of pertinent documents, it was determined that the facility failed to properly store medications securely and appropriately according to facility's policy and standard of clinical practice. The deficient practice was identified in 1 of 4 medication carts inspected on 3 of 3 units. The deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; [...]

Inspectors wroteBased on interview, record review, and review of other pertinent documents, it was determined that the facility failed to maintain a complete, available, accurate, and readily accessible medical records. This deficient practice was identified for 1 of the 35 residents reviewed (Residents #107). This deficient practice was evidenced by the following: During the initial tour of the 2nd-floor unit on 2/24/2025 at 10:49 AM, the surveyor observed Resident #107 lying on bed. On that same date and time, the resident informed the surveyor that they had weakness to the left side of their body due to stroke and claimed difficulty with walking. The resident further stated that they had incidents of falls in the facility, and unsure when and where in the facility the fall incidents happened. The resident's bed was not in a low position. [...]

Inspectors wroteREPEAT DEFICIENCY Based on observation, interview, review of medical records, and other pertinent facility documentation, it was determined that the facility failed to follow appropriate hand hygiene and use of personal protective equipment (PPE) practices for 1 of 3 staff (Licensed Practical Nurse) and follow appropriate infection control practices to prevent the potential spread of infection in accordance with the Center for Disease Control and Prevention (CDC) guidelines, standards of clinical practice, and the facility's policy. This deficient practice was evidenced by the following: According to the CDC Clinical Safety: Hand Hygiene for Healthcare Workers dated 02/27/24 revealed: Healthcare personnel should use an alcohol-based hand rub (ABHR) or wash with soap and water for the following clinical indications: Immediately before touching a patient . [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure facility staff had mandatory training that outlined and informed staff of the elements and goals of the facility's QAPI (quality assurance and performance improvement) program for 1 of five 5 Certified Nurse Assistants (CNAs) reviewed for mandatory education. This deficient practice was evidenced by the following: On 3/3/25 at 9:13 AM, the surveyor reviewed the annual in-service education hours for five randomly selected CNA files, which were provided by the facility. The Staff In-service Logs showed the following: CNA #1 had a date of hire (doh) of 1/25/18. According to the Transcript, CNA #1 did not have QAPI training. CNA #2 had a doh of 11/20/07. According to the Transcript, CNA #2 did not have QAPI training. [...]

Inspectors wroteComplaint #: NJ00162219 Based on record review staff interviews, and facility policy review, the facility failed to ensure an injury of unknown origin was reported to appropriate entities in a timely manner for one of eleven residents (Resident (R) 1) reviewed for abuse of 21 sample residents. R1 experienced an injury to her finger and the incident was not reported to the local Ombudsman, the family, or the State Agency.

Inspectors wroteC#: NJ00169205, NJ00162219 Based on record review, staff interviews, and facility policy review, the facility failed to ensure a thorough investigation was conducted related to injuries of unknown origin for two of eleven residents (Residents (R) 1 and R4) reviewed for abuse of 21 sample residents. R1 experienced an injury to her finger and R4 had a broken clavicle; these incidents were not investigated by the facility.

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to: a) follow a physician's order with regards to the use of an assistive device for one of three residents, Resident #5 reviewed for the limited range of motion (ROM); b) utilized the Braden Scale for Predicting Pressure Sore Risk (a standardized, evidence-based assessment tool commonly used in health care to assess and document a patient's risk for developing pressure ) for two of four residents, Residents #15 and #83 reviewed for pressure ulcers; c) follow a physician's recommendation and discontinuing a wound treatment for a healed wound in a timely manner for one of four residents (Resident#136) reviewed for wounds. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. [...]

Inspectors wroteBased on observation, interview and review of facility documentation, it was determined that the facility failed to ensure that the Certified Nursing Aide (CNA) received performance review for four of five CNA files reviewed. The deficient practice was evidenced by the following: On 01/12/23 at 12:50 PM, the surveyor requested from the Licensed Nursing Home Administrator (LNHA) the education, competencies and performance reviews for five CNA's. On 01/13/23, the facility provided the education and competencies for four of the five CNA's. The facility indicated that one of the five CNAs had resigned. The facility did not provide performance reviews for the five CNAs. On 01/17/23 at 01:45 PM, the surveyor, in the presence of the survey team and the Director of Nursing (DON), asked the LNHA to provide the performance reviews for the four CNAs. [...]

Inspectors wroteBased on observation, interview, and review of the facility provided documents, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to ensure a) expired narcotic medications were removed from active inventory b) dispensed and received medication from the pharmacy were reconciled for accuracy which resulted in the wrong dosage stocked in the active inventory c) expired biological from 6/22 were removed from active inventory This deficient practice was identified for one of one of the electronic emergency (backup) machine [name redacted] observed and was evidenced as follows: 1. On 01/17/23 at 9:59 AM, the surveyor received the [name redacted] Inventory report from the Director of Nursing (DON). [...]

Inspectors wroteBased on the interview and review of the facility provided documents, it was determined that the facility failed to ensure that the care planning (care conference meeting) was scheduled and that the resident's representative (RR) was provided sufficient notice in advance of the meeting according to the facility practice and policy for one of three quarters care conference reviewed for Resident#83. This deficient practice was evidenced by the following: On 01/11/23 at 8:58 AM, the RR informed the survey team that he/she visits Resident #83 almost every day. The RR had a concern that care planning meetings stopped since August 2022 and no invitation was provided to the RR. On 01/11/23 at 11:04 AM, the surveyor observed Resident #83 seated in a wheelchair, clean and well-dressed. The surveyor reviewed the medical record of Resident #83. The resident's admission Record (or face sheet; [...]

Inspectors wroteBased on observation, interview, and review of pertinent documents, the facility failed to ensure that the method for filing a grievance was consistent with the facility's practice and policy. This deficient practice was identified for three of four grievance incidents of Resident #83. The evidence was as follows: On 01/05/23 at 10:42 AM, during the Entrance Conference of the surveyor with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON), the LNHA stated that he started working at the facility three months ago. The DON stated that she started working on 12/15/22, the same time when both the previous DON and Infection Preventionist Nurse left the facility. On 01/11/23 at 8:58 AM, the resident representative (RR) informed the survey team that he/she visits Resident #83 almost every day. [...]

Inspectors wroteBased on observation, interview, and review of medical records, it was determined that the facility failed to develop a person-centered comprehensive care plan to address the actual skin impairments for one of four residents (Resident #15) reviewed for pressure ulcers. This deficient practice was evidenced by the following: On 01/05/23 at 10:42 AM, during the Entrance Conference of the surveyor with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON), the DON stated that she started working on 12/15/22, the same time when both the previous DON and Infection Preventionist Nurse (IPN) left the facility. The DON further stated that the IPN was also the Wound Nurse (WN). On 01/05/23 at 12:20 PM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM) who informed the surveyor that she was not sure if Resident #15 had facility-acquired wounds. [...]

Inspectors wroteBased on observation, interview, review of the medical record, and review of other facility documentation, it was determined that the facility failed to a) initiate a baseline care plan which included at risk for falls within 48 hours of admission and thoroughly and completely investigate a fall to include the addition of interventions to prevent a fall for one of four residents reviewed for falls, Resident #321; and b) failed to follow and maintain fall prevention interventions as written on the resident's plan of care for one of four residents reviewed for falls, Resident #132. The deficient practice was evidenced by the following: 1. On 01/05/23 at 12:05 PM, the surveyor observed Resident #321 in a reclined chair in the day room of the third floor unit. The resident's right side of the upper face was bruised. [...]

Inspectors wroteBased on observation, interview, and review of the facility provided documents, it was determined that the facility failed to ensure that the Registered Nurse (RN) had the specific competencies and skill sets necessary to care for residents' needs. This deficient practice was evidenced by the following: On 01/05/23 at 12:20 PM, the surveyor interviewed the Registered Nurse/Unit Manager (RN/UM) who informed the surveyor that she was not sure if Resident #15 had facility-acquired wounds. On 01/05/23 at 12:28 PM, the surveyor observed the resident seated with left foot dressing. The surveyor reviewed Resident #15's medical records. The admission Record (AR; [...]

Inspectors wroteBased on observation, interview, and review of pertinent documents, it was determined that the facility failed to maintain the kitchen in a sanitary manner as evidenced by the following: On 01/06/23 at 11:31 AM, the surveyor toured the kitchen on the second day with Food Service Director (FSD). The surveyor observed the food prep area with open food and kitchen staff preparing the lunch meal trays. Above the prep area were two kitchen tiles in between two air vents with an accumulation of black debris. At that time, the FSD stated that the black debris was an accumulation of dust. The surveyor asked the FSD regarding the cleaning schedule of air vents and above kitchen tiles. The FSD informed the surveyor that the air vents and above tiles should be cleaned once a month by the night shift kitchen staff and that there was a log for cleaning. [...]

Inspectors wroteBased on observation, interview, and review of the facility documents, it was determined that the facility failed to: a) perform hand hygiene appropriately for two of eight staff and, b) properly dispose of PPE (personal protective equipment) for one of two staff observed in TBP (transmission based precautions) room in accordance with the Centers for Disease Control and Prevention guidelines for infection control to mitigate the spread of COVID-19. This deficient practice was evidenced by the following: According to the U.S. CDC guidelines Hand Hygiene Recommendations, Guidance for Healthcare Providers (HCP) for Hand Hygiene and COVID-19, page last reviewed 1/8/2021 included that the HCP should perform hand hygiene before and after direct contact with the residents and immediately after glove removal. [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to complete a wound treatment in accordance with the physician's order. This was identified for 1 of 1 residents (Residents #135) reviewed for wounnd treatments. The deficient practice was evidenced by the following: Reference: New Jersey Statues, Annotated Title 45, Chapter. Nursing Board The Nurse Practice Act for the State of New Jersey states; The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and well being, and executing a medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: [...]

Inspectors wroteBased on observation, interview, record review and review of facility documents, it was determined that the facility failed to obtain a physician's order for the use of Oxygen and failed to maintain safe cleaning and storage of BiPAP (a Bi-level positive pressure airway ventilation machine to improve oxygenation) equipment according to professional standards of practice. This deficient practice was observed for 2 of 3 residents (Resident #21 and #177) reviewed for oxygen use and was evidenced by the following: 1. On 1/19/21 at 11 AM, the surveyor observed Resident #21 in bed awake and alert to person, place and date. The resident was receiving Oxygen 2 liters per minute (LPM) via a nasal cannula. The surveyor observed the tubing was dated 1/18/21. During the interview, the surveyor observed a BiPAP machine on top of the resident's dresser. [...]