CareOne at The Highlands: Wound Care Failures - NJ]
Inspectors visiting the facility on October 23, 2025 watched the nurse remove a soiled dressing from a resident's open wound and keep the same gloves on for everything that followed. With those gloves, she applied Santyl ointment directly onto a gauze pad. With those gloves, she placed the gauze onto the wound bed. With those gloves, she opened a Calcium Alginate dressing and packed the wound. Then, with the same gloves she had used to handle the soiled dressing, she reached into her own pocket, pulled out a pen, dated the foam dressing, and applied it.
She did not sanitize the over-bed table when she was done.
Then she removed her gloves, performed no hand hygiene, carried the unused supplies out of the room, and placed them back into the shared treatment cart.
The facility's own written procedure, last revised in September 2013, spells out what should have happened. Wash hands before putting on gloves. Remove the soiled dressing, pull the glove over it, discard both, then wash hands again before touching anything else. Cleanse the wound from the center outward, moving away from the wound bed to avoid dragging bacteria into it. Wash hands again before applying a new dressing. Clean the bedside stand. Wash hands a final time before leaving.
The nurse did none of those things in sequence. She confirmed as much.
At 10:55 that morning, the surveyor discussed the breaches with the nurse in the presence of the Director of Nursing. The nurse acknowledged that she should have removed her gloves and sanitized her hands after pulling off the soiled dressing. She acknowledged she should have cleansed the wound from the inside out rather than dragging potential contamination toward the wound bed. She acknowledged she should not have brought supplies into the room that she didn't intend to use, and that she should not have returned the unused supplies to the treatment cart afterward, where they could contaminate supplies meant for other residents. She acknowledged she should have sanitized the treatment cart.
The Director of Nursing confirmed every breach.
Later that afternoon, at 3:13 PM, the surveyor brought the findings to the Licensed Nursing Home Administrator and the Director of Nursing together.
The inspection was a complaint survey. Someone had a reason to call.
Wound infections are not abstract risks. An open wound is a direct route into the body's tissue. Bacteria introduced during dressing changes can cause localized infections that deepen into surrounding tissue or enter the bloodstream. The nurse's gloves had contacted a soiled dressing before touching medication, packing material, and the wound itself. Her ungloved hand then touched supplies that went back into a cart used for other residents' treatments.
CMS rated the harm level as minimal or potential for actual harm, affecting a few residents. That classification reflects what inspectors could document, not a ceiling on what could have resulted.
The procedure the nurse failed to follow had been written down for more than a decade. It was not new guidance. It was not complicated. It was a checklist of handwashing steps that exist precisely because the consequences of skipping them fall on people who are already sick enough to have open wounds.
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.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 24, 2026 · Our methodology
CareOne at The Highlands in EDISON, NJ was cited for violations during a health inspection on October 23, 2025.
With those gloves, she applied Santyl ointment directly onto a gauze pad.
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.