Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Careone At Livingston during CMS and state inspections, most recent first.
A resident with extensive burns and skin grafts did not receive timely or correctly ordered burn treatment as recommended by a consulting physician. The order for cocoa butter application was delayed and entered at a lower frequency than prescribed, and the product was not available for use until several days after approval. Both the LPN and DON confirmed the delay and the incorrect frequency of administration.
A resident assessed as low risk for pressure ulcers developed a facility-acquired pressure injury that was not promptly assessed or documented. Initial nursing notes described skin changes, but no wound assessment or new interventions were implemented at the time. The wound was not measured or staged until ten days later, and treatment orders were delayed. The DON confirmed that required assessment and documentation were not completed when the wound was first identified.
The facility failed to electronically transmit the MDS within the required 14 days for three residents and did not complete the discharge assessment for one resident. The delays were attributed to the lack of a full-time MDS Coordinator since December 2023, with only a part-time coordinator working remotely and regional staff overseeing the assessments.
A resident with anemia and chronic kidney disease did not receive Procrit as prescribed due to the LPN's failure to obtain necessary lab results, follow up with the pharmacy, or contact the physician for further instructions. The DON acknowledged the LPN did not follow proper procedures, leading to missed doses of Procrit on multiple occasions.
The facility failed to ensure medications were administered without error, resulting in a 12% error rate. Errors included improper timing of Glipizide administration, incorrect dosage of Docusate, and use of an incorrect Lidospot patch instead of the prescribed lidocaine 5% patch. These deficiencies were identified for two residents.
Delay and Incomplete Implementation of Burn Treatment Orders
Penalty
Summary
The facility failed to promptly implement a physician's recommendation for burn treatment and did not ensure the treatment was ordered at the recommended frequency. A resident with a history of extensive burns and skin grafts, who was cognitively intact, was admitted with orders from a Burn/Wound center physician to apply cocoa butter to all healed areas three times daily. However, the physician order entered into the Electronic Medical Record (EMR) two days after the consultation specified application only once per day shift and only to certain areas, not matching the recommended frequency or coverage. Further review showed that the cocoa butter was not available until several days after the order was approved, resulting in a delay in treatment. Interviews with the LPN and DON confirmed that the treatment was not provided as frequently as recommended and that there was a delay in obtaining the medication. The DON was unaware of both the delay in receiving the cocoa butter and the discrepancy in the frequency of administration compared to the physician's recommendation.
Failure to Timely Assess and Intervene for Facility-Acquired Pressure Ulcer
Penalty
Summary
A deficiency was identified when a resident, assessed as low risk for pressure ulcers, developed a facility-acquired pressure ulcer. Initial nursing documentation noted blanchable, thick, hard, indurated skin on the left buttock, but no wound assessment was completed at the time of identification. The physician and family were notified, but subsequent progress notes and monthly summaries failed to address or document the new wound. There was a lack of timely and thorough wound assessment, as the wound was not measured or staged until ten days after initial identification, at which point it was found to be an unstageable pressure injury by the wound specialist. The care plan for the resident included general interventions for skin integrity, such as barrier cream and preventative skincare, but no new interventions were added when the wound was first identified. Documentation conflicted regarding when specialty support surfaces were provided, and there were no corresponding physician orders or care plan entries for these interventions at the time of wound identification. Treatment orders for the wound were not initiated until several days after the wound was first noted, and the first administration of the treatment occurred a week later. Interviews with the DON confirmed that the wound was facility-acquired and that an initial assessment and documentation were not completed as required. The DON acknowledged that a documented assessment and measurement should have occurred when the wound was first identified. Facility policy required evaluation, reporting, and documentation of skin changes, as well as ongoing review of interventions, but these steps were not followed in this case.
Failure to Timely Transmit MDS and Complete Discharge Assessment
Penalty
Summary
The facility failed to electronically transmit the Minimum Data Set (MDS) within the required 14 days of completing the resident's assessment, as mandated by the Center's for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Manual. This deficiency was identified for three residents. Resident #25's Quarterly MDS assessment, with an Assessment Reference Date (ARD) of 12/11/23, was not submitted until 1/9/24. Resident #26's Admission MDS assessment, with an ARD of 2/13/24, was not submitted until 2/29/24. Resident #39's Annual MDS assessment, with an ARD of 10/21/23, was not submitted until 11/16/23, and a Quarterly MDS assessment with an ARD of 1/21/24 was not submitted until 2/8/24. The MDS Coordinator/RN confirmed these delays and attributed them to the lack of a full-time MDS Coordinator since December 2023, with only a part-time coordinator working remotely and regional staff overseeing the assessments. Additionally, the facility failed to complete the discharge assessment for Resident #48, who was discharged home on 11/30/24. The resident's electronic MDS records showed an Entry/MDS 3.0 accepted on 11/17/23 and a Medicare-5 day/MDS 3.0 completed on 11/24/23, but no discharge MDS was present. The Regional MDSC/RN acknowledged the missing discharge MDS during an interview and stated that she would open a discharge MDS immediately. The deficiencies were confirmed through interviews with the MDS Coordinator/RN and the Regional MDSC/RN, who both acknowledged the late submissions and the missing discharge assessment. The facility management did not provide any additional information during the survey team's meeting. According to the Long-Term Care Facility RAI 3.0 User's Manual, the MDS must be completed and transmitted within 14 days of the assessment being completed, and a discharge assessment must be completed and transmitted within 14 days of the discharge date.
Failure to Administer Procrit According to Physician's Order
Penalty
Summary
The facility failed to provide pharmaceutical services in accordance with professional standards by not ensuring the administration of Procrit according to a physician's order for a resident with anemia and chronic kidney disease. The resident's medical record indicated a physician's order for Procrit to be administered subcutaneously every Wednesday evening, with the condition to hold the medication if hemoglobin (Hgb) levels were 10 or greater. However, the electronic Medication Administration Record (eMAR) and nursing Progress Notes (ePN) showed discrepancies in the administration and documentation of Procrit, including instances where the medication was not administered due to the absence of Hgb results or lack of medication supply, without proper follow-up or documentation by the Licensed Practical Nurse (LPN). The LPN failed to obtain necessary lab results, follow up with the pharmacy, or contact the physician for further instructions, leading to missed doses of Procrit on multiple occasions in February and March. The Director of Nursing (DON) acknowledged that the LPN did not follow proper procedures for ensuring the lab results were obtained and the medication was administered according to the physician's order. The DON explained that on one occasion, the resident had gone to the hospital, resulting in no lab results to base the administration of Procrit. On another occasion, the lab results were obtained but not posted in time, and the LPN used outdated Hgb results to make a decision. Additionally, the LPN documented that the medication was not available on two dates but did not follow up with the pharmacy or report the issue to the next shift or administration. The facility's policy for administering medications states that medications should be administered in a safe and timely manner, as prescribed, and any results achieved should be recorded in the resident's medical record. The DON and Licensed Nursing Home Administrator (LNHA) stated that moving forward, any medication not available from the provider pharmacy should be reported to administration for additional follow-up to ensure either obtaining the medication or follow-up by a physician. The DON acknowledged that the LPN had attended an in-service training on the procedure to follow when a medication was not available but did not adhere to the procedure.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure that all medications were administered without error, resulting in a medication administration error rate of 12%. During the medication administration observation, the surveyor observed four nurses administering medications to six residents, with three errors out of 25 opportunities. One error involved an LPN administering Glipizide to an unsampled resident without ensuring it was given 30 minutes before the meal as required by the physician's order. Another error involved an LPN administering two capsules of Docusate 100mg to Resident #26 without confirming the correct dosage, as the order did not specify the strength or dosage. Additionally, the same LPN administered a Lidospot patch containing 4% lidocaine and 1% menthol instead of the prescribed lidocaine 5% patch, which was not available in the medication cart. The surveyor confirmed these errors through interviews with the LPNs and the Consultant Pharmacist, as well as a review of the electronic Medication Administration Record (eMAR) and medication information sheets. The facility's policy on administering medications, which requires medications to be administered in accordance with prescriber orders and within one hour of the prescribed time, was not followed. The policy also mandates that the individual administering the medication checks the label three times to verify the right resident, medication, dosage, time, and method of administration before giving the medication. These deficiencies were identified for two of the six residents observed during the survey.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Livingston
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Inglemoor Rehabilitation And Care Center | 2.3 mi | — | 0 | 0 |
| Cheshire Home | 2.7 mi | — | 8 | 0 |
| Livingston Post Acute Care | 2.7 mi | — | 21 | 0 |
| Stratford Manor Rehabilitation And Care Center | 2.9 mi | — | 10 | 0 |
| Alaris Health At West Orange | 3.6 mi | — | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.