Complete Care At Fair Lawn Edge
Inspection Findings
F-Tag F0755
F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Complaint # 2693362 Based on observation, interviews and review of other pertinent facility documents on 12/22/2025,12/23/2025 and 12/29/2025, it was determined that the facility failed to develop and implement
a procedure to safely acquire and receive physician ordered Methadone, (a controlled Substance) from a third party clinic; by assigning an unlicensed staff a Certified Nursing Assistant (CNA #1) to travel to an outside third party clinic to pick up Methadone (a controlled substance) for Residents #6,#7 and #8. CNA #1 would take the locked box with the key which contained the Methadone and drive to the facility in her personal car. An interview with the third-party's clinic staff and with facility's CNA #1 confirmed that CNA #1 picked up Methadone from the outside clinic and had access to the key for the box with the Methadone.
Review of document from the third-party clinic which was provided to the Department of Health (DOH) by
the facility, stated that CNA #1 performed this function of picking up the Methadone for residents on 11/19/2025 until 12/15/2025. During an interview on 12/22/2025 at 1:07 PM, with the Director of Nursing (DON), the surveyor asked the DON for the policy and procedure on receiving Methadone from the outside third part clinic. The DON stated that the facility had no policy. The DON confirmed the facility had residents
on Methadone, and that a Certified Nursing Assistant (CNA) or a nurse picked up the residents' Methadone from the clinic weekly or biweekly. The DON further stated that the Methadone was usually transported in a locked box by the nurse or CNA and was given to the unit nurse where the resident was located. The DON stated that she had an assigned CNA that picked up the Methadone from the third-party clinic, and if the assigned CNA was off, an arrangement was made for the CNA to come in for a couple of hours to go and pick up the Methadone.During an interview on 12/23/2025 at 1:56 PM, the Consultant Pharmacist stated that Methadone Clinic was not under his jurisdiction.During an interview on 12/23/25 at 2:16 PM, CNA #1 confirmed that she picked up Methadone from the outside clinic and that she delivered the box of Methadone and the key to the ADON or the DON when she arrived at the facility, and there were no discrepancies. During an interview on 12/29/25 at 9:25 AM, the DON in the presence of the Licensed Nursing Home Administrator (LNHA), stated that they did not have a specific policy and procedure for picking up Methadone from the outside clinic and that they used their general narcotic policy. The LNHA stated, that their corporate office only had the general narcotic policy but nothing specific about picking up Methadone.According to facility's policy dated 9/1/2024, with a revision date of 3/6/2025 and titled: Controlled Substance Administration and Accountability, it stated that controlled substances are delivered and signed for a licensed nurse.During an interview on 12/29/25 at 10:08 AM, the Registered Nurse (RN #1) stated that a CNA should not pick up Methadone because it was a narcotic medication, and CNAs do not handle narcotics or any type of medication. RN #1 further stated that a CNA should not handle or deliver narcotics or any sort of medication because they are not licensed. NJAC 8:39-29.4(k); 29.7(c)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
Facility ID:
If continuation sheet
Event ID:
COMPLETE CARE AT FAIR LAWN EDGE in PATERSON, NJ inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in PATERSON, NJ, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from COMPLETE CARE AT FAIR LAWN EDGE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.