Careone at Wellington

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to a) consistently ensure accountability and reconciliation of the controlled dangerous substances (CDS) - narcotic medications with high potential for abuse and drug diversion - for 1 of 3 medication carts inspected, and b) provide pharmaceutical services in accordance with professional standards to ensure appropriate administration of a medications for 1 of 5 residents (Resident #37) observed during medication administration. 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 wroteBased on interviews and review of pertinent documentation provided by the facility, it was determined that the facility failed to ensure that newly hired staff underwent a criminal background investigation prior to their date of hire. The deficient practice was observed for 2 of 118 employees hired after 1/7/25. The deficient practice was evidenced by the following:A review of the facility provided employee records reflected:Employee #11, a physical therapist was hired on 4/17/26 and had a no background check on file. Employee #67, a Certified Nursing Assistant was hired on 8/22/25 and the background check on file was dated 12/20/23 (1 year and 8 months prior to employment). On 6/15/26 at 10:10 AM, the surveyor and the survey team met with the Director of Nursing and the Licensed Nursing Home Administrator and discussed the background checks review of the facility's employee records. [...]

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 1 of 24 residents (Resident #37), who were reviewed for accuracy for MDS coding. This deficient practice was evidenced by the following: On 6/11/26 at 11:10 AM, the surveyor observed Resident #37 in the room awake, alert, and oriented, able to answer the surveyor in simple English. The surveyor and a Certified Nurse Assistant (CNA) who spoke Spanish interviewed Resident #37, who said that they are Spanish and Italian and can only speak either language, and they want an interpreter, if possible so they can understand better and answer the question appropriately. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to update and/or revise care plans for 1 of 27 residents reviewed, Resident # 9. The deficient practice was evidenced by the following: The surveyor reviewed an investigation for a fall Resident #9 had. The fall was on 4/28/26. The resident did not sustain any injuries. The investigation determined that the resident slipped and fell as the resident forgot to lock the wheelchair when attempting to transfer self. The investigation of the fall indicated that the Interdisciplinary Team agreed to add the following interventions to the care plan to prevent future falls; Provide assistance to transfer and ambulate as needed. The surveyor asked the Director of Nursing (DON) for all of the active care plans for the resident. [...]

Inspectors wroteBased on observation, interview, record review and review of pertinent facility documentation, it was determined that the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice for 1 of 3 residents, Resident #135, reviewed for wound care. 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 record review it was determined that facility nurses failed to consistently perform an accurate assessment of the resident's vascular access site for hemodialysis for 1 resident (#91) of 2 reviewed for dialysis care and services. The deficient practice is evidenced by the following. On 6/9/26 at 10:32 AM, the surveyor observed the resident in bed receiving morning care and again on 6/10/26 at 11:18 AM in bed with eyes closed. A review of the electronic medical record revealed the following information. The admission Record indicated the resident was admitted with end stage renal disease and was dependent on hemodialysis. The 4/29/26 admission Minimum Data Set (MDS) assessment tool, revealed the resident had no cognitive deficits (Section C) and received hemodialysis at the time of admission (Section O). [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure a medication was labeled in accordance with acceptable professional standards that identified the beyond used date (expiration date). This deficient practice was identified for 1 of 3 medication carts inspected during the medication and storage observation and was evidenced by the following:Reference: According to the manufacturer's specifications for Latanoprost, section 16 How Supplied/Storage and Handling included: Once a bottle is opened for use, it may be stored at room temperature 25 degrees Celsius (77-degree Fahrenheit) for 6 weeks. On 6/12/26 at 10:18 AM, during the inspection of the third-floor cart 2, the surveyors and the Licensed Practical Nurse (LPN) observed the following:- opened and undated Latanoprost eye drops (used to treat open-angle glaucoma). [...]

Inspectors wroteBased on observation, interview, record review and review of pertinent facility documentation, it was determined that the facility failed to follow appropriate infection control practices for 1 of 5 residents reviewed for infections (Resident #12). The deficient practice was evidenced by the following:On 6/10/26 at 11:10 AM, the surveyor observed Resident #12 receiving intravenous (IV) therapy from an electronic pump next to the bed. The surveyor observed there was no enhanced barrier precaution (EBP) signage or indicators at the entrance of the room. A review of Resident #12's electronic health record reflected the resident was receiving care for diagnoses that included but were not limited to leukocytosis (elevated white blood cell count), anemia, and vascular wounds of the left dorsal foot and left heel. [...]

Inspectors wroteBased on observation, interview, record review and review of pertinent facility documentation, it was determined that the facility failed to apply the principals of antibiotic stewardship during the treatment 1 of 5 residents reviewed for infections (Resident #12). The deficient practice was evidenced by the following: On 6/10/26 at 11:10 AM, during the initial tour of the facility, the surveyor observed Resident #12 receiving intravenous (IV) therapy from an electronic pump next to the resident's bed. On 6/10/26 at 11:45, the surveyor reviewed Resident 12's electronic health record (EHR). The review of the EHR reflected the resident was receiving care for diagnoses that included but were not limited to; leukocytosis (elevated white blood cell count), vascular wounds of the left dorsal foot and left heel and anemia. [...]

Inspectors wroteComplaint #: NJ186848 Based on observation, interviews, and review of pertinent facility documents on 6/2/25, it was determined that the facility failed to provide adequate supervision to a cognitively impaired resident (Resident #1) with a known history of elopement which resulted in the resident eloping on 5/26/25. This deficient practice was identified for 1 of 4 residents reviewed for risk for elopement (Resident #1). Resident #1, a cognitively impaired resident who wore a wander guard to alert staff of possible elopement, was last seen by staff on 5/26/25 at 3:45 PM. The Licensed Practical Nurse (LPN #1) reported that the resident wanted to go downstairs for dinner, and she disarmed the elevator's wander guard system to allow the resident to self-propel themselves in their wheelchair downstairs. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents it was determined that the facility failed to maintain sanitation in a safe and consistent manner to prevent food borne illness. This deficient practice was evidenced by the following: On 12/30/24 at 9:19 AM, the surveyor, in the presence of the Culinary Service Director (CSD) observed the following during the kitchen tour: 1. On the dry rack storage shelf, there were a stack of three half sheet pans. The surveyor observed 1 of the 3 stacked half sheet pans was soiled with white solid debris on the inside of the pan. The CSD was able to scratch the debris off and acknowledged that the pan was soiled. The surveyor observed 1 of the 3 stacked half sheet pans was wet on the inside portion. The CSD acknowledged it was wet and that it should have been dried before stacking with the other pans. [...]

Inspectors wroteBased on observation, interview, record review and review of pertinent facility documentation, it was determined that the facility failed to use appropriate infection control practices specifically for: a) Nursing not wearing the required Personal Protective Equipment (PPE) when entering the room of a resident on Transmission-Based Precautions (TBP) (LPN #1); b) Houskeeping (H) staff not removing soiled PPE when exiting the room of a resident on TBP (H #1, #2, #3); c) a Unit Secretary (US) wearing her surgical mask inappropriately below her nose and mouth while on the unit hallway; and d) Certified Nursing Assistants (CNA) not following appropriate hand hygiene during meal service (CNA #1, #2, #3, #4). The deficient practice was evidenced by the following: Reference: Use personal protective equipment (PPE) appropriately, including gloves and gown. [...]

Inspectors wroteBased on interviews, and review of pertinent facility documents, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards to ensure accurate documentation of a) the receipt of a controlled substance for three (3) of three (3) Schedule II controlled substance medications ordered and received by the facility for use as an emergency backup supply, on one (1) Drug Enforcement Agency (DEA) 222 Forms (a form used to order controlled substances from a provider) reviewed and b) two (2) of two (2) controlled substances were accurately accounted for on two (2) of two (2) Controlled Drug Administration Records (CDAR) observed in one (1) of three (3) medication carts. The deficient practice was evidenced by the following: Reference: 21 CFR 1305.13 Procedure for filling DEA Forms 222. Reference: New Jersey Statutes Annotated, Title 45. [...]

Inspectors wroteBased on observation, interview, record review, and review of other pertinent documents, it was determined that the facility failed to ensure that all medications (meds) were administered with an error rate of less than 5%. During the medication administration observation conducted on 12/311/24, the surveyor observed three (3) nurses administer meds to six (6) residents. There were twenty-six (26) opportunities, and three (3) errors were observed which resulted in a medication error rate of 15.38%. This deficient practice was identified for two (2) of six (6) residents observed (Resident #15 and an unsampled resident), which was administered by one (1) of three (3) nurses. 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, and review of pertinent facility documents, it was determined that the facility failed to properly store medication for 2 of 3 medication carts inspected according to facility's policy and 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; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to maintain the dignity of an unsampled residents. This deficient practice was found with 4 of 4 Certified Nursing Aides (CNA) observed during a dining observation on the third floor. The deficient practice was evidenced by the following: On 12/31/24 at 12:08 PM, during a lunch meal dining observation on the 2nd floor in the main dining room, the surveyor observed the lunch trays being distributed to the residents by four CNA's. The four CNA's passed out the trays to each resident and left the trays on the table underneath each of the resident's plates. There were three insulated lids left in the middle of the tables and the CNA's were observed placing wrappers and garbage inside those lids. The lids remained on the tables throughout the entire meal. [...]

Inspectors wroteBased on observation, interview, record review, and review of other facility documentation, it was determined the facility failed to ensure accurate documentation and review of a resident's advance directives for 1 of 2 residents (Resident #21) reviewed. This deficient practice was evidenced by the following: The surveyor reviewed the paper chart and electronic medical records of Resident #21. The admission Record (a summary of important information about the resident) documented Resident #21 had diagnoses that included but were not limited to, Alzheimer's disease, heart failure, and atrial fibrillation (an irregular, often rapid heart rate). A comprehensive Minimum Data Set (MDS) assessment, a tool to facilitate the management of care, dated 10/28/24, indicated the facility assessed the resident's cognition using a Brief Interview Mental Status (BIMS) test. [...]

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 18 residents (Resident #67 and #70), reviewed for MDS coding accuracy. On 1/10/25 at 10:20 AM, the surveyor reviewed the electronic medical record (EMR) of Resident #67. The admission Record (a summary of important information about the resident) revealed that Resident #67 was male. An entry record for the MDS assessment dated [DATE] revealed under Section A (Identification Information), A0800-Gender, the resident was coded as female. A comprehensive MDS assessment dated [DATE] revealed under section A (Identification Information), A0800-Gender, the resident was coded as female. The surveyor reviewed the EMR of Resident #70. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to change respiratory nasal cannula (NC) tubing according to infection control standards of practice and failed to ensure that it was stored in accordance with infection control measures for one of one resident reviewed for Respiratory therapy, Resident #24. 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 NJ00170288 Based on interview, medical record review, and review of other pertinent documentation it was determined that the facility failed to ensure that residents who receive hemodialysis (HD) receive such services consistent with professional standards of practice for 1 of 2 residents (Resident #191) reviewed for dialysis services. The deficient practice was evidenced by the following: On 1/2/25 the surveyor reviewed a Reportable Event Record/Report submitted by the facility Director of Nursing (DON) to the NJ Department of Health (DOH) on 11/29/23. The Report summarized an event which occurred on 11/26/23. Resident #191 returned from the HD clinic on the evening of 11/25/23. [...]

Inspectors wroteBased on interview, record review, and review of facility documentation, it was determined that the facility failed to ensure that the resident did not receive an unnecessary medication for one (1) of twenty-four (24) residents reviewed, (Resident #85). The deficient practice was evidenced by the following: The surveyor reviewed Resident #73's electronic medical record (EMR) which revealed the following: A review of Resident #85's admission Record (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to COVID-19, heart disease, and urinary tract infection. [...]

Inspectors wroteComplaint #: NJ00179638 Based on interviews, record review and review of pertinent facility documents on 11/18/2024 and 11/19/2024, it was determined that the facility failed to ensure the safety of a resident (Resident #1) when: (a) the Resident took his/her p.o. [by mouth] medication with a clear liquid which was given by Registered Nurse (RN) #1. Resident #1 drank the liquid and reported a burning sensation when swallowing and notified RN #1. It was revealed the clear liquid was a Dakin's solution [a wound cleanser solution] half-strength (Sodium Hypochlorite 0.25%); (b) RN #1 did not follow facility's proper procedure in preparing liquid solutions for wound care, and (c) RN #1 did not follow facility's procedure in accordance to professional standards of nursing practice in administration of medication in a safe and timely manner. [...]

Inspectors wroteComplaint # NJ00166908, NJ00162689 Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to report to the New Jersey Department of Health (NJDOH) within 24 hours for an allegation of a resident-to resident verbal altercation. The deficient practice was identified for 2 of 3 investigations of reportable incidents reviewed (Resident #62, #195, #55). This deficient practice was evidenced by the following: 1. On 10/3/23 at 10:40 AM, the surveyor observed Resident #62 ambulating in the hallway of the 2nd floor. The surveyor interviewed the resident who was pleasant and verbalized no concerns. The surveyor reviewed Resident #62's hybrid medical records. The resident's admission Record (an admission summary) indicated Resident #62 was admitted to the facility with diagnoses that included but was not limited to Dementia. [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to develop a comprehensive, person-centered care plan for 2 of 27 residents reviewed for comprehensive care plans (Resident #14 and #72). This deficient practice was evidenced by the following: 1. On 10/3/23 at 10:57 AM, the surveyor observed Resident #14, resting in bed in their room. Resident #14 was receiving oxygen via a nasal cannula (NC-plastic prongs attached to a tube, inserted into the nostrils that oxygen flows through) that was attached to a concentrator (an oxygen delivery system). The concentrator was set a 2 LPM (liters per minute). On 10/4/23 at 10:45 AM, the surveyor observed Resident #14 resting in bed. The resident was receiving oxygen via NC that was attached to a concentrator set at 2 LPM. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to obtain a physician's order (PO) for the wound treatment of four pressure ulcer wounds. This deficient practice was observed for 1 of 3 residents (Resident #22) reviewed for pressure ulcers. This deficient practice was evidenced by the following: On 10/3/23 at 10:55 AM, the surveyor observed Resident #22 resting in bed on a specialized pressure relieving mattress. The resident was alert, oriented, and verbally responsive. Resident #22 stated they had wounds on their back that were being treated. The surveyor reviewed the electronic health record (EHR) for Resident #22 which revealed the following: [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to: a) obtain a physician's order (PO) for a resident receiving oxygen therapy, and b) ensure a resident received oxygen therapy as ordered by the physician. This deficient practice was identified in 2 of 2 residents (Resident #14, and #72), who were reviewed for respiratory care. The deficient practice was evidenced by the following: 1. On 10/3/23 at 10:57 AM, the surveyor observed Resident #14, resting in bed in their room. Resident #14 was receiving oxygen via a nasal cannula (NC-plastic prongs attached to a tube, inserted into the nostrils that oxygen flows through) that was attached to a concentrator (an oxygen delivery system). The concentrator was set a 2 LPM (liters per minute). On 10/4/23 at 10:45 AM, the surveyor observed Resident #14 resting in bed. [...]

Inspectors wroteBased on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to monitor a resident's hemodialysis (the clinical purification of blood by dialysis, as a substitute for the normal function of the kidney) treatment access site. This deficient practice was identified for 1 of 2 residents (Resident #343) reviewed for dialysis. This deficient practice was evidenced by the following: On 10/4/23 at 11:16 AM, the surveyor observed Resident #343 sitting on their bed eating breakfast. Resident #343 was alert, oriented, and verbalized no concerns about their care. A review of the electronic health record (EHR) of Resident #343 revealed the following: [...]

Inspectors wroteBased on observation, interview, and review of facility policies, it was determined that the facility failed to properly store, label, and discard potentially hazardous foods in a manner to prevent food borne illness. This deficient practice was evidenced by the following: On 10/3/23 at 9:20 AM, the surveyor in the presence of the Culinary Director (CD) observed the following during the kitchen tour: 1. Under the Chef's Prep table, the surveyor observed an opened 1-gallon container of liquid butter alternative, which had no opened or discard date. The CD stated the container should have been labeled with an opened and discard date. 2. On a shelf above the Chef's Prep table, the surveyor observed two opened 16-ounce(oz.) spice containers of ground cloves and chili pepper. The two spice containers had no opened or discard date. [...]