CareOne at Livingston: Wound Care Medication Failure - NJ
The burn and wound center physician had ordered cocoa butter to be applied three times per day. The facility administered it once.
The Director of Nursing acknowledged both failures during the inspection. She told investigators she had not known the cocoa butter was being given only once daily rather than the three times the specialist had specified. She also confirmed the medication should have been available to the resident on August 22, 2025, the day it was ordered, or by the following day at the latest. It was not.
The inspection, conducted on October 23, 2025, was triggered by a complaint. Investigators cited the facility under F0684, the federal standard requiring that residents receive care consistent with professional standards of practice. The level of harm was listed as minimal harm or potential for actual harm. A few residents were identified as affected.
What the report does not explain is how long the resident went without the full prescribed treatment. The gap between August 22, the order date, and the October inspection is two months. The inspection narrative does not specify when the dosing error was caught, whether it was corrected before investigators arrived, or what effect the reduced application had on the wound's progress.
Cocoa butter is used in burn and wound care to maintain skin moisture and support healing. A specialist prescribing it three times daily is setting a treatment rhythm based on the wound's needs. Cutting that to once daily is not a minor scheduling adjustment.
The Director of Nursing did not dispute the findings. She confirmed the frequency discrepancy, confirmed the delay in availability, and acknowledged both represented failures. What she offered was that she had not been aware. The order existed. The medication was available, eventually. But the instruction from the specialist, the part that said three times a day, did not make it into the resident's daily care in the way it was written.
CareOne at Livingston is located at 68 Passaic Avenue. The facility's plan of correction was not included in the inspection materials reviewed.
The resident's wound, and whether it healed, is not something the inspection report addresses.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Careone At Livingston from 2025-10-23 including all violations, facility responses, and corrective action plans.
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 7, 2026 · Our methodology
CAREONE AT LIVINGSTON in LIVINGSTON, NJ was cited for violations during a health inspection on October 23, 2025.
The burn and wound center physician had ordered cocoa butter to be applied three times per day.
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.