CareOne at The Highlands: Medication Delays Uninvestigated - NJ
The inspection, conducted October 23, 2025, stemmed from a complaint. Federal surveyors found that when Resident #1 arrived at the facility, medications were not available. That gap, and what happened next, or what didn't happen, became the center of the investigation.
LPN #1 told surveyors she had contacted the physician. She acknowledged she was supposed to document that contact in the resident's progress notes. She could not say what follow-up the physician had instructed her to do. She told surveyors there were no backup medications available at the facility and that she had waited for the pharmacy to send them. She also acknowledged she had never documented that she had contacted the pharmacy.
The electronic medication administration record told the same story: continued entries showing the medication was not available, with no documentation that anyone had called the physician or the pharmacy, and no record of what either had said.
The Director of Nursing sat down with surveyors that same afternoon. She said backup medications were available at the facility, but clarified that inhalers and steroid creams were not among them. She walked through what nurses were supposed to do when a medication wasn't on hand: call the physician for follow-up orders, ask about substituting a similar available medication, or obtain a physician's order to hold the medication until the pharmacy could deliver it. The pharmacy also needed to be called to confirm the delivery was coming. All of that, she said, should happen the first time a medication is found to be unavailable. All of it should be documented in the progress notes.
She acknowledged that the EMAR for Resident #1 should not have shown repeated entries of a medication being unavailable without any corresponding documentation of those calls being made.
Inhalers, she said, presented a particular challenge because there were no backup inhalers kept in the facility. In those situations, she explained, the physician might order something different, or staff could reach out to the resident's family, or a physician's order would indicate to hold the medication until the pharmacy delivered it. None of those options appeared to have been pursued, or at least none were documented.
The Director of Nursing also described the standard timing problem for new admissions: a resident admitted on the 3 PM to 11 PM shift would not receive medications until noon or 1 PM the next day. The physician, she said, should be made aware of that gap, and a physician's order would indicate when to start the medication. That, too, is the kind of communication that is supposed to be documented.
Surveyors cited the facility under New Jersey regulations governing medication administration.
The inspection found minimal harm or potential for minimal harm, and noted that few residents were affected. Those classifications, in the federal inspection system, sit at the lower end of the severity scale. But the gap between what the Director of Nursing described as standard practice and what LPN #1 was able to account for was unambiguous. The nurse couldn't say what the doctor told her. She couldn't say she had called the pharmacy. The record showed neither call had been documented.
Resident #1 went without an inhaler. How long, and what that meant for the resident's breathing, the inspection report does not say.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Careone At the Highlands from 2025-10-23 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 5, 2026 · Our methodology
CareOne at The Highlands in EDISON, NJ was cited for violations during a health inspection on October 23, 2025.
The inspection, conducted October 23, 2025, stemmed from a complaint.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.