Careone at Somerset Valley

Inspectors wroteBased on observation, interview and review of pertinent documents it was determined that the facility failed to ensure that equipment functioned in a manner to ensure dishes and dishware were appropriately cleaned and the appropriate measuring device was utilized to ensure proper sanitizer concentrations were maintained to limit the potential from microbial contamination and potential food borne illness. This deficient practice was evidenced by the following:On 4/6/26 at 5:11 PM, two surveyors toured the kitchen with the Executive Chef (EC) and observed the following:The dish machine was in use, and one staff member was placing dirty dish racks into the dish machine which appeared to be a high temperature machine, and the wash temperature was at 158 degrees Fahrenheit (F). The EC stated there was a leak in a water line at the back of the dish machine and that it was taped. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to provide care and services in a manner that maintained and promoted dignity by failing to have residents dressed in a dignified manner during the group meal time and activities. This deficient practice was identified for 2 of 2 cognitively impaired residents reviewed for dignity (Resident #11 and Resident #29) was evidenced by the following:1. On 04/06/26 at 5:55 PM, during the initial tour, the surveyor observed Resident #11 seated in a wheelchair in the main dining room wearing only their incontinent brief and hospital type gown. The Licensed Practical Nurse (LPN) who was in the hallway next to their room informed the surveyor that Resident #11 had developmental disabilities and could not communicate their needs. A strong offensive urine odor also permeated from the room. [...]

Inspectors wroteBased on observation, interview, and document review, it was determined that the facility failed to maintain a clean and sanitary environment for 1 of 13 resident rooms (Room # 16) observed. The deficient practice was evidenced by the followingOn 04/06/26 at 5:55 PM, the surveyor in the presence of another surveyor toured the facility, and both surveyors entered Room # 16 occupied by Resident #11 and Resident # 5 and observed the following:The curtain was visibly soiled with a large amount of yellow substance. There was an offensive and lingering odor of urine in the room. A Certified Nurse Aide (CNA) was in the room and stated that she just provided incontinence care to Resident #11 and the urine odor persisted in the room. On 4/6/25 at 6:45 PM, the surveyor returned to the room and the offensive urine odor of urine was very strong. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to consistently ensure a) the medication administration record was not signed prior to medication administration, b) medication was administered in accordance with manufacturer specifications and c) cautionary instructions were included for proper administration. The deficient practice was identified for 2 of 5 residents (Resident #26 and #54), who were administered medication by 2 of 4 nurses observed and was evidenced by the following:a) On 4/7/26 at 9:14 AM, the surveyor observed Registered Nurse (RN) preparing medications for Resident #26. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure 1 of 2 antiretroviral medications (Tivicay) used to treat Human Immunodeficiency (HIV) was available which resulted in 6 missed doses, and was administered in accordance with the physician order and professional standards of practice and the facility policy of medication administration. The deficient practice was identified for 1 of 5 residents (Resident #26), and medication administered by 1 of 4 nurses observed and was evidenced by the following:On 4/7/26 at 9:14 AM, the surveyor observed Registered Nurse (RN #1) prepare medications for Resident #26 that included Tivicay (Dolutegravir) 50 milligrams (mg), 1 tablet by mouth one time a day for HIV, initiated on 3/17/26 and was resident's own medication. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to fully inform in advance the resident representative of a resident who had no capacity to consent to the risk of using psychotropic medications, benefits, alternative options and of the black box warning (Deemed by the the Food and Drug Administration to possiblly cause severe harm). This deficient practice was identified for 1 of 5 residents (Resident #11) reviewed for unnecessary medications and was evidenced by the following:On 04/08/26 at 10:08 AM, the surveyor reviewed the medical records of Resident #11. According to the admission Record, (face sheet) an admission summary, Resident #11 was admitted to the facility with diagnoses which included but were not limited to; [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to provide residents with the care needed to meet the residents highest practical level for residents who were dependent on staff for bathing. This deficient practice was identified for 1 of 3 residents (Resident #5) reviewed for Activity of Daily Living (ADL) care . The deficient practice was evidenced by the following:On 4/6/26 at 5:55 PM, during the initial tour the surveyor observed Resident #5 in their room and the room had a strong odor of urine, and the curtain was visibly soiled. The resident was nonverbal and could not communicate with the surveyor. On 4/6/26 at 6:45 PM, the surveyor interviewed the Licensed Practical Nurse (LPN) observed in the hallway next to Resident #5's room. The LPN stated that Resident #5 was dependent on staff for all care. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to maintain the appropriate oxygen administration for 1 of 1 resident (Resident #39) reviewed for respiratory care. This deficient practice was evidenced by the following:On 4/6/2026 at 5:27 PM, the surveyor observed Resident #39 in bed, with the head of the bed elevated, receiving oxygen (O2) via nasal cannula (NC-a tube with two prongs at the end that deliver oxygen through the nose) being delivered by an O2 concentrator set at 4.5 liters per minute (LPM). No humidification was present. On 4/7/26 at 7:50 AM, Surveyor #2 observed the Registered Nurse (RN) knock on Resident #39's door then entered the room with a blood pressure machine in preparation for medication administration. [...]

Inspectors wroteComplaint #'s: NJ 169236, 173607 Based on observation, interview, record review, and document review, it was determined that the facility failed to provide sufficient nursing staff to ensure all residents reached their highest practical wellbeing by failing to: a) provide timely incontinence care, b) provide consistent timely call bell response for resident assistance, c) ensure meals and water were in reach for residents who were deemed dependent with care needs , d) maintain the required minimum direct care staff-to-shift ratios as mandated by the state of New Jersey and had the potential to affect all residents who resided at the facility. The deficient practice was evidenced by the following: Refer to F558, F677, S560 and S1680 Surveyor #1: [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to maintain an environment and resident care to limit the spread of potential infection by failing to: a) adhere to acceptable standards of infection control practices for the cleaning and storage of shared glucometer after each resident use. This deficient practice was observed during medication administration and for 1 of 3 medication carts (Cart #2), b) ensure that respiratory masks and tubing were properly stored to prevent the spread of potential infection. This deficient practice was identified for 2 of 2 residents reviewed for respiratory care, Resident #22 and #61, c) mitigate the spread of infection by using a contaminated disinfectant wipe to wipe a clean surface and perform adequate hand hygiene per facility policy. [...]

Inspectors wroteBased on observation, interview, record review and review of pertinent documentation, it was determined that the facility failed to follow professional standards of practice by administering Midodrine (medication to increase blood pressure) outside of the physician parameters. This deficient practice was identified for 1 of 15 residents (Resident #40) reviewed for medications 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 169236, 173607 Based on observation, interview, review of records, and review of pertinent documents, it was determined that the facility failed to provide appropriate incontinence care for 2 of 13 residents reviewed for Activities of Daily Living (ADL), Resident # 110 and #112. The deficient practice was evidenced by the following: a. On 10/30/24 at 8:45 AM, the surveyor entered Resident #110's room and the resident stated they were soiled and staff would not answer the call light. At 9:00 AM, the surveyor observed incontinence care with Certified Nurse Aide (CNA) #1. Resident #110's incontinence brief was observed saturated with urine. The surveyor exited the room and returned at 9:40 AM. Resident #110 informed the surveyor again that they had not yet been provided with incontinence care. [...]

Inspectors wroteComplaint # NJ 169236, 173607 Based on observation, interview, and record review it was determined that the facility failed to ensure the resident's bedside table and the call light was accessible. The deficient practice was identified for 1 of 15 residents reviewed (#112) for accommodation of need and was evidenced by the following: On 10/30/24 at 9:53 AM, the surveyor observed Resident #112 in bed. The resident appeared upset and informed the surveyor that they were admitted to the facility on [DATE] at 4:00 PM. Resident #112 stated they had diarrhea at that time, their lips were dry and could not get a sip of water all night. The Resident stated that they activated the call light and no one entered the room to inquire regarding their concerns. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to maintain a medication error rate below 5%. The surveyors observed three nurse administer 30 doses of medication to four residents and there were 3 errors which resulted in a medication error rate of 7.6%. On 10/31/2024 at 7:24 AM, the surveyor observed the Licensed Practical Nurse (LPN) administer medication to a resident on her assignment. The unsampled resident was administered Metoprolol Succinate ER (extended release) Tablet Extended Release 24 Hour 100 MG (milligram) Give 1 tablet by mouth one time a day for HTN (hypertension) Take with or immediately following meals. At the time of the medication administration, the facility breakfast trays were not delivered, and the LPN had not provided, offered, or instructed the resident to take the medication with food. [...]

Inspectors wroteBased on observation, interview and review of facility documents, it was determined that the facility failed to ensure that medications were labeled and dated upon opening, expired medications were removed from active inventory upon expiration: This deficient practice was identified on 1 of 3 medications carts inspected and was evidenced by the following: On 10/30/24 at 12:15 PM, in the presence of the Licensed Practical Nurse (LPN) the surveyor inspected the low hall medication cart on the sub-acute unit. The surveyor observed a Humalog insulin pen (a medication used to treat high blood sugar) with an expiration date of 10/27/24. An other insulin pen which was delivered on 10/22/24. The Insulin pen was opened and not dated. On 10/30/24 at 12:45 PM, the surveyor interviewed the LPN responsible for the medication cart. [...]

Inspectors wroteComplaint #NJ 160833 Based on observation, interview, and review of pertinent documents, it was determined that the facility failed to communicate the unavailability of medications from the pharmacy to the physician in accordance with professional standards of practice. This deficient practice was identified for 2 of 18 residents (Resident #16 and #217) reviewed for standards of practice 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 wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to store, label, and date potentially hazardous foods to prevent food-borne illnesses. This deficient practice was evidenced by the following: On 09/08/2023 at 9:30 AM, the surveyor, in the presence of the Food Service Director (FSD), toured the kitchen and observed the following: 1. In the dry storage room, there was a 2-pound bag of dry roasted sea salt peanuts that was wrapped in clear plastic with a label with an opened date of 07/12/23 and used by 07/25/23. The FSD discarded them. 2. In the reach-in freezer, there was a 5 lb. bag of cheese medium-squared ravioli that was opened and wrapped in clear plastic not labelled or dated. The FSD discarded them. 3. [...]