Careone at Holmdel

In the surveyor’s words

From the most serious findings on record at Careone at Holmdel, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF922Mar 13, 2024

  Based on observations, interviews, and pertinent facilty documents it was determined that the facility failed to maintain the designated emergency supply of water needed for residents in the event of a loss of normal water supply. This deficient practice was evidenced by the following: On 3/04/24 at 10:22 AM, the surveyor conducted an entrance conference with the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON). The facility was licensed for 120 beds and the facility census was 86 (the number of residents who currently resided at the facility). On 3/04/24 at 9:30 AM, the surveyor conducted a kitchen tour with the Food Service Director (FSD), in the presence of a second surveyor. […]

• No harm, potential for more than minimal, patternF686Mar 13, 2024

  Complaint NJ# 164959 Based on observation, interviews, record review and review of pertinent facility documentation, it was determined that the facility failed to (a) document the measurement of a pressure ulcer (an injury to the skin and underlying tissue resulting from prolonged pressure on the skin), and (b) obtain a physician's order for wound care for a resident admitted with a community-acquired pressure ulcer in accordance with professional standards of practice. This deficient practice was identified for 1 of 3 resident's (Resident #70) reviewed for pressure ulcers. This deficient practice was evidenced by the following: On 3/4/24 at 11:33 AM, the surveyor observed Resident #70 lying in bed. […]

• No harm, potential for more than minimal, patternF692Mar 13, 2024

  Based on observation, interviews, record review, and review of pertinent facility documentation, it was determined that the facility failed to obtain, record and monitor weights on admission, readmission and weekly in accordance with professional standards of practice. This deficient practice was identified for 1 of 6 residents (Resident #82) reviewed for nutrition. The deficient practice was evidenced as follows: On 03/11/24 at 12:30 PM, the surveyor observed Resident #82 in bed, awake, and alert. The resident was observed independently feeding themselves and had eaten 75% of lunch. […]

• No harm, potential for more than minimal, isolatedF557Jul 31, 2025

  Based on observation, record review, interview, and review of facility policy, the facility failed to promote the dignity of one (Resident (R) 63) of 13 residents reviewed with indwelling catheters from a sample of 24 residents when R63 was observed with urinary drainage bag without a privacy covering. This had the potential for the residents to have a diminished quality of life. Findings include: Review of the facility policy titled Dignity with a review date of February 2021 revealed. Demeaning practices and standards of care that compromise dignity are prohibited. Staff are expected to promote dignity and assist residents; for example, helping the resident to keep urinary catheter bags covered. […]

• No harm, potential for more than minimal, isolatedF605Jul 31, 2025

  Based on interview, record review, and facility policy review, the facility failed to ensure the monitoring of target behaviors for the use of Seroquel (an antipsychotic medication) for one of five sampled residents (Resident (R) 28) reviewed for unnecessary medications out of a total sample of 24. This had the potential for the resident to be administered unnecessary or the incorrect does medication due to not knowing if the medication was effective.Findings include:Review of the facility's policy titled, Psychopharmacologic Medication revised 09/06/18 revealed, MONITORING: Monitor residents for targeted behaviors and medication side effects, who are receiving the following classes: Antipsychotic, Anxiolytic (or Antianxiety), Sedative/Hypnotic & Specific Mood stabilizers and… […]