Careone at the Highlands

Inspectors wroteComplaint Survey Complaint # NJ00187927F686 D Based on observation, interview, record review, and review of other pertinent facility documents, it was determined that the facility failed to maintain infection control standards and procedures during wound care treatment for 1 of 2 Residents (Resident #2) reviewed for care and services for pressure ulcers. 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: [...]

Inspectors wroteCOMPLAINT #NJ00187927Based on interview, record review and review of pertinent facility documents, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards by ensuring two medications (Breo Ellipta Aerosol (a combination inhaler used to prevent and control symptoms of asthma) and Triamcinolone topical cream (a steroid cream)) were obtained in a timely manner and administered as per prescribed physician's orders for one (1) of four (4) residents sampled. 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: [...]

Inspectors wroteREPEAT DEFICIENCY Based on interviews 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 7 of 12 residents (Residents #5, #21, #26, #46, #51, #88 and #242), who were reviewed for MDS coding accuracy. This deficient practice was evidenced by the following: 1. On 5/21/25 at 12:30 PM, the surveyor observed Resident #5 sitting in the bed, awake and alert, able to answer the surveyor's inquiry. On 5/22/25 at 11:33 AM, the surveyor reviewed the electronic Health Record (eHR)/hybrid medical record (paper and electronic) of Resident #5, which revealed the following: [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to inform the resident or their representative in advance of treatment risks and benefits, options, and alternatives to a resident receiving antipsychotic and opioid medications. This deficient practice was identified for 3 of 7 residents (Resident #5, 26, and #51) reviewed for unnecessary medications. This deficient practice was evidenced by the following: 1. On 5/21/25 at 12:30 PM, the surveyor observed Resident #5 sitting in the bed, awake and alert, able to answer the surveyor's inquiry. Resident #5 stated that they are not informed about the medication they are receiving. On 5/22/25 at 11:33 AM, the surveyor reviewed the hybrid medical record (paper and electronic) of Resident #5, which revealed the following: [...]

Inspectors wroteComplaint #NJ00174157 Based on interview, record review, and review of pertinent documents, it was determined that the facility failed to report an injury of unknown origin to the New Jersey Department of Health (NJDOH) promptly for 1 of 2 residents (Resident #143) reviewed for investigations and was evidenced by the following: A review of Resident #143's Face Sheet (an admission summary) reflected that the resident was admitted to the facility with diagnose that included but were not limited to dysphagia (difficulty swallowing), atherosclerotic heart disease(a buildup of plaque in or on the artery walls) and pain in the left knee. A review of Resident 143's admission Minimum Data Set (MDS), an assessment tool dated 5/9/24, reflected that the resident had a brief interview for mental status score of 10 out of 15 which indicated the resident had moderate cognitive impairment. [...]

Inspectors wroteOn 5/22/25 at 12:35 PM, the surveyor observed Resident #16 in bed, with both eyes closed with a urinary drainage bag in a privacy bag hanging on the bed frame. The surveyor reviewed Resident #16's electronic medical records. A review of the admission Record, an admission summary revealed the resident had diagnoses which included but were not limited to hypertension (high blood pressure), benign prostatic hyperplasia (enlarged prostate) and retention of urine (difficulty urinating). A review of the physician order summary (POS) dated active orders included an order dated 5/1/25 for urinary catheter care every shift. Further review revealed an order dated 5/1/25 for urinary catheter size 16F Coude balloon size 10 ml, change prn for obstruction as needed change catheter if obstructed. [...]

Inspectors wroteREPEAT DEFICIENCY Based on observation, interview, and record review, it was determined that the facility failed a.) to follow a Physician's Order (PO) and b.) create a PO for an Oxygen (O2) dependent resident in accordance with professional standards of practice for 2 of 2 residents, (Resident #26 and # 82), reviewed for respiratory care. 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: [...]

Inspectors wroteREPEAT DEFICIENCY Based on observation, interview, and record review, it was determined that the facility failed to document the physician's order as prescribed accurately. This deficient practice was identified for 1 (one) of 7 residents (Resident #46) reviewed for unnecessary medications. 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: [...]

Inspectors wroteBased on observation, interview, review of medical records and other facility documentation, it was determined that the facility failed to follow appropriate infection control procedures during medication administration. This deficient practice was identified for 1 of 3 nurses observed during the medication administration observation. On [DATE] at 8:47 AM, the surveyor during medication pass observation of the registered nurse (RN), made the following observations: The RN prepared the oral medication for Resident #44, set them aside and began to prepared 3 Lidocaine external patches 4% patches (to relieve pain), artificial tears solution 1.4% eye dropsused to relieve dry eyes) , and Lovenox injection solution prefilled syringe 40 mg/0.4 ml (used to prevent blood clots). [...]

Inspectors wroteComplaint: NJ00180728 Based on interviews, medical record reviews, and review of pertinent facility documents on 05/14/2025 and 05/16/2025, it was determined that the facility failed to follow their, Accidents and Incidents - Investigating and Reporting policy, and conduct a thorough investigation after a resident was found on the floor after a fire alarm for 1 of 3 residents (Resident #6) reviewed for accidents and incidents. This deficient practice was evidenced by the following: Review of the admission Record revealed that Resident #6 was admitted to the facility with diagnoses that included but were not limited to unspecified atrial flutter (rapid pumping in the heart's upper chambers resulting in palpitations, shortness of breath, and fatigue); anemia (unspecified); Type 2 diabetes mellitus without complications; muscle weakness (generalized); [...]

Inspectors wroteComplaint: NJ00180728 Based on interviews, record review, and review of pertinent facility documents on 05/14/2025 and 05/16/2025 it was determined that the facility failed to follow the facility policy Weight Assessment and Intervention and follow physician orders (POs) for weekly weights. This deficient practice was identified for 1 of 3 residents (Resident #6) reviewed for nutrition. The deficient practice was evidenced by the following: The admission Record revealed that Resident #6 was admitted to the facility with diagnoses that included but were not limited to anemia (unspecified); Type 2 diabetes mellitus without complications; unspecified severe protein-calorie malnutrition; muscle weakness (generalized); dysphagia, oral phase; and cognitive communication deficit. Review of Resident #6's Minimum Data Set (MDS), an assessment tool, dated 11/08/2024, was conducted. [...]

Inspectors wroteComplaint # NJ 00174172 Based on interview, medical records (MR) review, and review of pertinent facility documents on 8/8/24 and 8/12/24, it was determined that the facility failed to report an injury of unknown origin to the New Jersey Department of Health (NJDOH) and follow their facility policy on Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating for 2 of 5 sampled residents (Resident #2 and Resident #4) reviewed for investigation and reporting. This deficient practice was evidenced by the following: 1. According to the admission Record (AR), Resident #2 was admitted to the facility with diagnoses which included but were not limited to unspecified Dementia, Difficulty in Walking, and Muscle Weakness. [...]

Inspectors wroteC# NJ00174172 Based on interviews, and record review, as well as review of pertinent facility documents on 8/8/2024 and 8/12/2024, it was determined that the facility failed to ensure that the residents' care plan (CP) was revised for 2 of 5 (Resident #2 and Resident #4) reviewed for CP revision. This deficiency is evidenced by the following: 1. According to the admission RECORD (AR), Resident #2 was admitted with diagnoses that included but were not limited to: Dementia, Muscle Weakness, Cognitive Communication Deficit, and Difficulty in Walking. The Minimum Date Set (MDS), an assessment tool dated 3/10/2024, indicated that the Resident had a Brief Interview for Mental Status (BIMS) of 0/15 which indicated the Resident's cognition was severely impaired and needed help during Activities of Daily Living (ADL). [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to maintain dignity during mealtime for a resident who needed assistance with eating. This deficient practice was observed for 2 of 26 residents observed, Resident #27 and Resident #72 and was evidenced by the following: 1. On 1/4/24 at 12:09 PM, the surveyor observed the Certified Nurse's Aide (CNA) on the [NAME] Unit, standing and holding a supplement in her right hand while Resident #27 was drinking the supplement via a straw. The surveyor also observed the CNA observing and holding her personal cellphone in her left hand while assisting the resident during feeding. The surveyor interviewed the CNA on 1/4/23 at 12:14 PM, who stated that she normally stands while feeding the resident because she was also assisting another resident (Resident #27's roommate) at the same time in the same room. [...]

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to maintain the confidentiality of the resident information on the Electronic Health Records system. This deficient practice was observed during unit observation and was evidenced by the following: On 1/8/24 at 1:11 PM, the surveyor observed a paper documenting written information placed on top of the medication cart showing resident's photos, resident's names, resident's room numbers, vital signs including blood pressure, heart rate, blood glucose level, and temperature associated with each resident. Further observation revealed other documented notes about the residents next to their names. The surveyor observed two family members passed by the medication cart where the paper was placed having documented information available for viewing by anyone passing by. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to complete and transmit a Minimum Data Set (MDS) - Discharge Assessment in accordance with federal guidelines. This deficient practice was identified for 1 of 26 residents reviewed for resident assessment, Resident #84. This deficient practice was evidenced by: On 1/9/24 at 11:22 AM, the surveyor reviewed the facility assessment task that included the Resident's MDS Assessments. The MDS is a comprehensive tool that is a federal mandated process for clinical assessment of all residents that must be completed and transmitted to the Quality Measure System. The facility must electronically transmit the MDS within 14 days of the assessment being completed. After transition of the MDS, a quality measure will be transmitted to enable a facility to monitor the residents decline or progress. [...]

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 26 residents, Resident #105 and Resident #47, reviewed for accuracy of MDS coding. This deficient practice was evidenced by the following: 1. On 1/11/24 at 2:18 PM, the surveyor reviewed the closed hybrid (paper and electronic) medical records for Resident #105. A review of the admission Record (a summary of important information about the resident) documented Resident #105 with diagnoses that included but were not limited to Chronic Kidney Disease, Hematuria, Anemia, and Muscle Weakness. [...]

Inspectors wroteComplaint #NJ00154940 Complaint #NJ 00153394 Based on observation, interview, and record review it was determined that the facility failed to accurately document and clarify the administration of medication for 3 of 36 residents, Resident #39, #43 and #21. 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 registered professional nurse is defined as diagnosing and treating human responses to actual and 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 wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: [...]

Inspectors wroteBased on observation, interview, and review of pertinent medical records, it was determined that the facility failed to follow physician orders related to the use of continuous oxygen (O2) for 1 of 1 resident, Resident #15, reviewed for O2 therapy. This deficient practice was evidenced by the following: On 1/4/24 at 11:00 AM, the surveyor observed Resident #15 seated in a wheelchair in their room. Resident #15 was receiving O2 delivered through a nasal cannula (NC) (plastic prongs attached to a tube, inserted into the nostrils that oxygen flows through) utilizing a concentrator (an oxygen delivery system) at 4 Liters per minute (LPM). The surveyor reviewed the resident's paper and electronic medical chart. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to ensure that the residents' primary physician signed and dated monthly physician orders (PO) to ensure that the residents' current medical regimen was current and accurate. This deficient practice was observed for 4 of 46 residents reviewed, Resident #76, Resident #51, Resident #47, and Resident #27 and was evidenced by the following: 1. On 1/4/24 at 11:27 AM, the surveyor observed Resident #76 in bed alert and responsive. The surveyor reviewed the admission Record (one page summary of important information about a resident) (AR) for Resident #76. The resident was admitted to the facility with diagnoses that included but was not limited to End Stage Renal Disease; Major Depressive Disorder; Cognitive Communication Deficit and Muscle Weakness. [...]

Inspectors wroteBased on interview, and record review, it was determined that the facility failed to ensure that the responsible physician supervising the care of residents conducted face to face visits and wrote progress notes at least once every sixty days. This deficient practice was identified for 1 of 26, Resident #76, reviewed for physician visits and was evidenced by the following: 1. On 1/4/24 at 11:27 AM, the surveyor observed Resident #76 in bed. When interviewed, Resident #76 was noted alert and responsive. The surveyor reviewed the admission Record (one page summary of important information about a resident) for Resident #76. The resident was admitted to the facility with diagnoses that included but were not limited to End Stage Renal Disease; Major Depressive Disorder; Cognitive Communication Deficit and Muscle Weakness. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure that expired and discontinued medications were removed from active inventory after it had expired and/or had been discontinued by the physician in accordance with professional standards of clinical practice. This deficient practice was identified for 2 of 2 units inspected involving Resident #6, #28, #36, #49, #66, #90, #260, #263, #265, #266, #268, #269 and #270, This deficient practice was evidence by the following: 1. On 1/4/2024 at 11:47 AM, the surveyor inspected the [NAME] Unit Nursing Station. Inspection of the [NAME] Unit Nursing Station resulted in the absence of an Emergency Kit (designed to help nursing facilities provide medication to their residents during emergency situations). [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the Consultant Pharmacist (CP) failed to clarify medication dosage for a newly admitted resident to the facility during the initial medication review for 1 of 1 Residents, Resident #21. The deficient practice was evidenced by the following: On 1/4/24 at 11:16 AM, the surveyor interviewed Resident # 21 in the resident's room. The resident stated they had anxiety which they took the medication sertraline (Zoloft) and they had been receiving the incorrect dose. Resident #21 explained that prior to admission to the facility they were receiving 75 milligrams (mg) of sertraline and since admission to the facility had been receiving 50mg daily. The resident stated they noticed this about a week ago. Resident #21 reported to a staff member and had not heard anything since that time. [...]

Inspectors wroteBased on observation, interview, and review of facility policies, it was determined that the facility failed to maintain proper kitchen sanitation practices as well as discard potentially hazardous foods in a manner to prevent food borne illness. This deficient practice was observed and evidenced by the following: On 1/04/24 09:17 AM, the surveyor in the presence of the Culinary Director (CD), observed the following during the kitchen tour: 1. On a storage shelf below Chef Preparation Table #3, the surveyor observed an opened one (1) gallon bottle of molasses with a label that read, use by 12/10/23. 2. In the food preparation area, the surveyor observed dietary aide (DA) #1 with hair not fully restrained under their hairnet and DA #2 wore large, hooped earrings. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to maintain complete and readily accessible medical records. This deficient practice was identified for 1 of 22 residents reviewed (Resident #42). This deficient practice was evidenced by the following: On 1/5/24 at 11:02 AM, the surveyor observed Resident #42 in their room sitting in a reclining chair, watching television. The resident was awake, alert, and verbally responsive to simple questions. On 1/11/24 at 12:20 PM, the surveyor reviewed the hybrid (paper and electronic) medical records of Resident #42. According to the admission Record (an admission summary), Resident #42 had diagnoses that included but were not limited to: Epilepsy, Type 2 Diabetes Mellitus, muscle weakness, dysphagia, and Chronic Obstructive Pulmonary Disease. [...]

Inspectors wroteBased on observation, interview, it was determined that the facility failed to maintain proper infection control practices which was identified during dining observation and was evidenced by the following: On 1/9/24 at 12:28 PM, the surveyor observed a Certified Nursing Assistant (CNA) in the [NAME] Wing dining room and was holding a clear plastic bag. In addition the surveyor observed the CNA walking towards a resident who was eating their lunch. The CNA was observed touching the resident's meal tray and the resident's utensils while holding the clear bag. The surveyor interviewed the CNA who stated that the clear bag contained a dirty bib (food protector) for one of the residents who was also in the dining room. [...]

Inspectors wroteComplaint #NJ00154940 Complaint #NJ00150195 Complaint #NJ00151010 Refer to deficiencies F658, F755 Based on observation, interview, record review, and review of facility provided documentation, it was determined that the facility failed to maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey. This deficient practice was evidenced by the following: Reference: New Jersey Department of Health (NJDOH) memo, dated 1/28/2021, Compliance with N.J.S.A. (New Jersey Statutes Annotated) 30:13-18, new minimum staffing requirements for nursing homes, indicated the New Jersey Governor signed into law P.L. 2020 c 112, codified at N.J.S.A. 30:13-18 (the Act), which established minimum staffing requirements in nursing homes. The following ratio(s) were effective on 2/01/21: [...]