Citations in New Jersey
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in New Jersey.
Statistics for New Jersey (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in New Jersey
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain a licensed pharmacist, resulting in a lack of required pharmaceutical oversight.
Surveyors identified that the facility failed to accurately code the MDS for two residents. One resident with a history of MDRO and recent insulin use was not coded for these conditions on the MDS, despite care plan and MAR documentation. Another resident with severe cognitive impairment was not coded for a recent fall on the MDS, even though care plan records and family reports indicated a fall had occurred. These discrepancies were based on direct observation, record review, and interviews.
The facility did not adequately protect resident-identifiable information or maintain medical records according to professional standards, as observed by surveyors.
Two residents experienced falls when staff failed to follow care plan interventions requiring two-person assistance for transfers. In one case, a resident with severe cognitive and mobility impairments was transferred alone with a mechanical lift and without a neck collar, resulting in a head injury and hospitalization. In another case, a resident requiring maximum assistance was transferred by a single CNA, leading to a fall to the floor.
A resident with quadriplegia and neurogenic bowel filed a grievance after wound care was provided but not documented in the medical record. Review of the TAR and Progress Notes showed no evidence that the wound vacuum dressing change and skin prep were completed as ordered, despite staff confirming the care was given. The LPN admitted to forgetting to document the treatment, resulting in an incomplete medical record.
The facility did not ensure that residents were protected from all forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
Surveyors found that the facility did not ensure an area was free from accident hazards and failed to provide adequate supervision to prevent accidents. The environment did not meet safety standards, and insufficient supervision was observed.
The facility did not ensure that residents were protected from abuse, including physical, mental, and sexual abuse, physical punishment, and neglect by any person.
The facility did not promptly report suspected abuse, neglect, or theft, nor did it communicate the results of its investigation to the proper authorities as required.
Nursing staff did not consistently document medication administration on the MAR for two residents, leaving blank spaces for scheduled medications without corresponding notes. Interviews with an LPN and the DON confirmed that facility policy requires all medication administrations, refusals, or holds to be documented, and that blank spaces are not acceptable. Review of the facility's policy also supported the need for complete MAR documentation.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist Oversight
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated by regulations.
Inaccurate MDS Coding for Two Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for two residents, resulting in deficiencies related to the management of care. For one resident, observations revealed signage and personal protective equipment indicating Enhanced Barrier Precautions (EBP) due to a history of multiple drug-resistant organisms (MDRO) in the urine. The resident's care plan documented EBP for MDRO and insulin therapy for diabetes, and the Medication Administration Record showed insulin administration during the assessment period. However, the quarterly MDS did not reflect the resident's history of MDRO or insulin use in the relevant sections. For another resident, a review of the medical record and care plan indicated a diagnosis of hypertensive heart disease and dementia, with a severely impaired cognitive status. The admission MDS documented no falls in the 2-6 months prior to admission, but the baseline care plan and other documentation noted a fall in the relevant period as reported by the resident's daughter. Additional assessments identified the resident as being at risk for falls due to an unsteady gait. The discrepancies between the MDS coding and supporting documentation contributed to the deficiency.
Failure to Safeguard Resident Information and Maintain Medical Records
Penalty
Summary
The facility failed to safeguard resident-identifiable information and/or did not maintain medical records for each resident in accordance with accepted professional standards. This deficiency was identified through surveyor observation or review, indicating that the required protocols for protecting confidential information and proper record-keeping were not consistently followed. No additional details regarding specific residents, their medical history, or the exact nature of the records involved are provided in the report.
Failure to Follow Care Plan Transfer Interventions Results in Resident Falls
Penalty
Summary
The facility failed to provide a safe environment and did not follow fall prevention interventions as outlined in the individual comprehensive care plans for two residents. In one instance, a resident with a history of severe cognitive impairment, traumatic brain injury, and a cervical vertebra fracture required two-person assistance and a neck collar for all transfers. Despite this, a CNA attempted to transfer the resident alone using a mechanical lift, without the neck collar in place. The resident fell, sustained a head laceration requiring emergency hospital transfer, and was admitted for eight days with three staples placed in the occipital area. In another case, a resident with impaired mobility and chronic medical conditions required maximum assistance for transfers, specifically with two staff members and the use of a gait belt and walker. A CNA attempted to transfer the resident alone, resulting in the resident sitting/falling onto the floor. The resident denied injury, but the incident demonstrated that the care plan interventions for safe transfer were not followed. Both incidents were confirmed through review of medical records, care plans, staff interviews, and facility documentation. The facility's own policies required adherence to care plan recommendations and the presence of two staff members for mechanical lift transfers, which was not followed in these cases.
Failure to Document Wound Care Provided to Resident
Penalty
Summary
A deficiency was identified when the facility failed to maintain accurate and complete medical records for a resident with quadriplegia, neurogenic bowel, and neuromuscular bladder dysfunction. The resident, who was cognitively intact, filed a grievance indicating that a nurse had changed their wound dressing following a bowel movement. However, a review of the Treatment Administration Record (TAR) and Progress Notes for the relevant date showed no documentation that the wound vacuum dressing was changed or that skin prep was applied, as ordered. The facility's policy required all services provided to be documented in the resident's medical record. Interviews with the resident, an LPN shift supervisor, and the Director of Nursing confirmed that the wound care was provided, but the LPN admitted to forgetting to document the treatment due to a shift change. The DON also acknowledged that documentation should have been completed to reflect the care provided. The lack of documentation resulted in an incomplete medical record, contrary to facility policy and accepted professional standards.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by anybody. This deficiency indicates that residents were not adequately safeguarded from potential or actual harm caused by others, as required by regulations. The report identifies a lapse in the facility's responsibility to ensure a safe environment free from abuse and neglect for all residents. No specific details about the actions, inactions, or events leading to the deficiency, nor information about the residents involved or their medical conditions, are provided in the report.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified in the facility's failure to ensure that an area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could contribute to the risk of accidents for residents. Specific actions or inactions leading to this deficiency include the presence of accident hazards and insufficient supervision, as directly observed by surveyors during their assessment. No additional details about individual residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
The facility failed to protect residents from all types of abuse, including physical, mental, and sexual abuse, as well as physical punishment and neglect by any individual. This deficiency indicates that there was an incident or incidents where residents were not safeguarded from such harm, as required by regulations. The report does not provide specific details about the actions or inactions of staff, the events that led to the abuse or neglect, or information about the residents involved.
Failure to Timely Report Suspected Abuse, Neglect, or Theft
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft and did not report the results of the investigation to the proper authorities. This deficiency was identified based on the facility's lack of prompt action in notifying the appropriate agencies when an incident of suspected abuse, neglect, or theft occurred. The report indicates that the required notifications and investigation results were not communicated as mandated.
Failure to Document Medication Administration on MAR
Penalty
Summary
Facility nursing staff failed to consistently document medication administration on the Medication Administration Record (MAR) for two residents. For one resident with diagnoses including major depressive disorder, anxiety disorder, and asthma, there was a blank entry on the MAR for a scheduled dose of Tylenol Extra Strength, and no corresponding documentation in the progress notes to indicate whether the medication was administered. For another resident with anemia, diabetes, and hypertension, blank spaces were found on the MAR for scheduled applications of Clobetasol Propionate cream, with no documentation in the progress notes to confirm administration. Interviews with the LPN and the Director of Nursing confirmed that facility policy requires nurses to sign the MAR after administering medications and to document refusals or held medications with appropriate codes, ensuring no blank spaces are left. Both staff members acknowledged that the MARs for the two residents contained blank spaces, which was not in accordance with facility policy or professional standards. Review of the facility's medication administration policy further supported the requirement for timely and complete documentation on the MAR.
Some of the Latest Corrective Actions taken by Facilities in New Jersey
- Re-educated all staff on the abuse policy regarding when and to whom to report abuse allegations (J - F0610 - NJ)
- Re-educated the LNHA on the abuse and investigation sections of the abuse policy (J - F0610 - NJ)
Failure to Maintain Safe Hot Water Temperatures Resulting in Immediate Jeopardy
Penalty
Summary
The facility failed to maintain hot water temperatures at a safe level on one of its nursing units, specifically the C-Wing, resulting in water temperatures ranging from 137.1°F to 138.4°F in resident rooms and the shower room. These temperatures were significantly above the safe range of 95°F to 110°F, as acknowledged by both the Regional Licensed Nursing Home Administrator (RLNHA) and the Maintenance Director (MD). The C-Wing unit, which included cognitively impaired residents, was serviced by a separate boiler that lacked a temperature gauge and was found set to high. Multiple staff, including the RLNHA, confirmed the excessive temperatures and agreed that such conditions could cause burns. Residents on the C-Wing reported that the hot water was so hot it could be used to make tea or instant noodle soup, indicating prolonged exposure to unsafe water temperatures. One resident with fully intact cognition and another with moderately impaired cognition both confirmed the water had been excessively hot for some time. The surveyors directly measured the high temperatures in the presence of facility staff, who acknowledged the findings. Despite daily water temperature checks being claimed by the MD, the temperature logs for C-Wing were incomplete and did not show any recent entries, nor did they specify the locations where temperatures were taken. The facility did not have a written water temperature policy and relied on regulatory standards. The lack of documentation and monitoring, combined with the absence of a temperature gauge on the C-Wing boiler, contributed to the failure to detect and address the hazardous water temperatures. The issue was identified during a survey following a recent fire that had affected utilities, but the facility's staff denied any prior issues with high water temperatures. The deficiency was found to have placed residents, including those with cognitive impairments, at risk of serious injury from scalding.
Removal Plan
- The Maintenance Director lowered the hot water temperature on the boiler.
- Water temperatures were obtained throughout every residents' room in the facility.
- The facility initiated water temperatures to be taken every two hours for three days.
- All residents on C-Wing were assessed for skin damage.
- The facility conducted a resident council meeting to discuss safe water temperatures with the residents.
- The Director of Nursing/designee initiated a house-wide staff in-service on safe water temperatures, the process of taking water temperatures, and any staff not in-serviced would be prior to their next shift.
Failure to Thoroughly Investigate Abuse Allegation and Notify Authorities
Penalty
Summary
The facility failed to thoroughly investigate an abuse allegation involving a Certified Nursing Assistant (CNA) and a resident. After being notified by Ombudsman representatives that a CNA was attempting to get a resident out of bed while the resident was screaming, the Licensed Nursing Home Administrator (LNHA) suspended the CNA and conducted an investigation. However, the LNHA did not interview other residents who had received care from the CNA, as required by the facility's abuse investigation policy. The LNHA also did not notify local police of the abuse allegation, believing police notification was only necessary for serious injuries or elopements. The resident involved had a history of dementia, depression, and required moderate assistance with activities of daily living. During the incident, the resident reported pain and bruising to the left arm, which was confirmed by a Registered Nurse's assessment. Another resident later reported to the surveyor that the same CNA had previously humiliated and mistreated them, but had only reported this to the Ombudsman and not to facility staff. The LNHA confirmed that she did not follow up with other residents or obtain statements from them regarding the CNA's conduct, nor did she ask the Ombudsman for the identities of residents who had complaints. The facility's failure to follow its own abuse investigation policy, specifically the requirement to interview other residents cared for by the accused staff member, resulted in the CNA returning to work after the initial allegation. This allowed the CNA to continue providing care until further complaints were brought to the LNHA's attention by the Ombudsman, at which point the CNA was terminated. The lack of a thorough investigation and failure to notify authorities constituted a deficiency in the facility's response to alleged abuse.
Removal Plan
- CNA #1 was terminated from the facility
- The LNHA conducted an investigation into abuse allegations involving CNA #1, which included resident interviews
- All facility staff were re-educated on the facility's abuse policy regarding when to report abuse allegations and to whom
- The facility's owner re-educated the LNHA on the abuse and investigation sections of the abuse policy
- The Director of Nursing (DON) conducted audits to see if any residents had experienced any form of abuse
Explore Popular Searches
