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
A cognitively impaired resident with dysphagia was ordered a pureed diet with nectar-thick liquids and had a care plan identifying aspiration risk and the need for thickened liquids. A family member brought in a smoothie from outside and, after asking an RN about it, was told the resident was supposed to receive nectar-thick liquids; however, the RN did not verify whether the smoothie was given, did not document any follow-up, and did not notify the physician. No incident report was completed, and the care plan was not updated with interventions regarding outside food, contrary to facility policy requiring reporting and physician notification of incidents.
Two residents were affected by failures in medication administration and documentation. A resident with moderate cognitive impairment reported being given an antacid and offered a thyroid pill they were not prescribed, and staff statements confirmed that a nurse administered omeprazole intended for another resident, contrary to the requirement to verify the right resident and right drug. Another resident with a traumatic brain injury, cancer, and a G-tube had a PRN order for ondansetron for nausea/vomiting; vomiting and nausea episodes were documented in progress notes, but there was no corresponding documentation that the PRN ondansetron was given or any explanation for not administering it, and when ondansetron was documented as given in progress notes, the MAR was not signed to reflect those administrations.
Surveyors found that the facility failed to maintain complete medical records for two residents. One resident with cognitive impairment, multiple fractures, and a high fall risk required substantial assistance with ADLs, yet there was no documentation that the private aide assigned to provide companionship was educated on the resident’s care needs or instructed not to provide hands-on care, even though the aide later reported independently assisting the resident after a fall. For another cognitively impaired resident with an indwelling Foley catheter, progress notes documented that the catheter had dislodged, but did not include any recorded vital signs or pain assessment at the time of the event, despite facility policies requiring complete documentation of services, changes in condition, and vital sign monitoring when clinically indicated.
A resident with multiple comorbidities, including recent pneumonia, thrombocytopenia risk, and renal issues, had weekly CBC/BMP labs ordered. One set of labs showed a critically low platelet count and significantly worsened renal function. The overnight LPN received the critical values and sent a text to the physician instead of establishing direct voice contact, then later texted about another resident. The physician only saw and responded to the second text and stated he never saw the message about the critical platelet count. No direct call was made, no new orders were obtained, and the critical results were not effectively communicated for approximately three days. The issue came to light when the resident’s representative questioned the labs during a care plan meeting, prompting a unit manager to call the physician, who then reviewed the results and ordered transfer to the ER. Interviews and policy review showed that facility expectations and protocols required emergent, direct phone communication and escalation for critical labs, which did not occur in this case, resulting in delayed care and treatment.
A resident with acute kidney failure, diabetes, and a UTI had a urine culture collected, and the abnormal result was reported to the facility but not promptly communicated to a practitioner. Facility staff, including the UM/LPN and DON, stated that nurses are expected to notify providers as soon as abnormal lab results are received and that clinicians, although able to access labs in the electronic record, rely on nursing notification. The resident’s abnormal urine culture was not acted upon until several days later, when an NP reviewed the result, noted a severe UTI, and ordered antibiotics, and the NP confirmed this delay in notification and treatment was contrary to expectations and represented a delay in care.
A resident with dementia, severely impaired cognition (BIMS 0), behavioral issues including disrobing, and C-diff on contact precautions was served dinner in a wheelchair by a CNA who placed a sheet over the resident’s lap to prevent tampering with briefs or pants. When the sheet repeatedly fell, the CNA loosely tied it around the resident’s waist and behind the wheelchair, creating a physical restraint that restricted the resident’s movement and access to their body. The resident’s family later entered the room, found the resident alone with the dinner tray in place and the sheet wrapped and tied around the waist and wheelchair, and alerted staff. The nursing supervisor confirmed the sheet was tied around the resident and wheelchair, with no staff present, and removed it. This restraint use was contrary to facility policy, which allowed restraints only to treat medical symptoms and not for staff convenience, and resulted in an Immediate Jeopardy finding.
The facility did not maintain a qualified full-time SW despite being licensed for 180 beds, as required by CMS guidelines and state regulations. The LNHA and HRD reported that the full-time SW position had been vacant for several months, with only a part-time or per diem SW providing limited hours before also leaving shortly before the survey. Timecard records showed very low SW hours over multiple pay periods, confirming the lack of full-time coverage. The facility’s own SW job description emphasized responsibility for ensuring residents’ medically related emotional and social needs were met, highlighting the significance of the vacancy.
The facility failed to provide adequate medically related social services, including psychosocial support after an abuse allegation and assistance with discharge planning and community resources. A resident with dementia and mobility dependence was allegedly treated roughly by a CNA during a transfer, but there was no documentation that social services monitored the resident’s psychosocial status as required by facility policy. Another resident with intact cognition, diabetic complications, neuropathy, and an amputation repeatedly requested help from a SW to obtain a phone and community housing, but received limited and partly incorrect assistance and could not complete provided forms due to neuropathy. A third cognitively intact resident with complex medical conditions and a stated goal of community discharge reported a difficult discharge process, and the family stated there was no SW involvement or family meeting, with family members performing most discharge arrangements and no SS progress notes documenting discharge planning.
A resident with dementia, muscle weakness, and dependence on staff for transfers reported back pain and requested to return to bed, and an insurance case worker later alleged that a CNA handled the resident roughly during the transfer, with the resident saying "ow." Although the CNA was suspended during the investigation and the allegation was ultimately unsubstantiated, the resident’s care plan was only updated with a vague focus on documented concerns and generic nursing and Social Services notifications, without clear goals or specific interventions related to the abuse allegation. The UM and RDON acknowledged that the care plan did not clearly address the allegation as required by facility policy for individualized, revised care plans.
The facility failed to maintain a complete facility assessment (FA) that accurately reflected the behavioral and mental health needs of its resident population and the resources available to meet those needs. The FA referenced psychiatric and mood disorders and indicated that behavioral and mental health services and contracted mental health professionals were used, but it did not identify the specific contracted providers or list any psychiatrists, psychologists, or licensed counselors. The section stating that behavioral health staffing was adequate for residents with dementia, mental health conditions, or trauma history contained no supporting evidence. During interviews, the LNHA and DON acknowledged that the FA was incomplete, despite a large population of residents with mental health and behavioral issues and a facility policy requiring a comprehensive, regularly updated FA addressing resident needs, services, staff competencies, and staffing patterns for all shifts.
Failure to Ensure Ordered Nectar-Thick Liquids and Follow-Up on Outside Food
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a cognitively impaired resident consistently received nectar-thick liquids as ordered and to implement interventions to prevent the resident from receiving liquids inconsistent with the prescribed diet. The resident had diagnoses including metabolic encephalopathy, dysphagia (oral phase), and unspecified dementia with severely impaired cognitive skills for daily decision making, as documented on the quarterly MDS. Physician orders specified a regular diet with pureed texture and nectar (mildly thick) liquids, and the care plan identified a risk for aspiration related to dementia and the resident’s preference not to be assisted during meals, with interventions including monitoring for aspiration signs and providing thickened liquids as ordered. On a documented date, the resident’s family member brought an outside smoothie into the facility and asked RN #1 if it was acceptable to give it to the resident. RN #1 informed the family member that the resident was supposed to receive nectar-thick liquids, but the family member stated that the smoothie looked acceptable and that the resident would only have a taste. The progress note recorded that the smoothie cup contained approximately 45 cc (1.5 oz) of smoothie and that RN #1 did not witness the smoothie being given to the resident. There was no documentation that RN #1 followed up with the family member to determine whether the smoothie was actually given or how much was consumed. The record review and interviews further showed that there was no incident/accident report completed for this event, and no documentation that the physician was notified of the potential administration of an inappropriate fluid consistency, despite facility policy requiring all incidents and accidents to be reported to the nursing supervisor and the attending physician. The DON and UM acknowledged that the family member should have been educated, the physician notified, and the care plan updated with new interventions related to outside food, but these actions were not taken. The facility also did not implement measures to prevent recurrence of similar incidents involving outside food inconsistent with ordered diet and fluid thickness.
Failure to Follow Medication Orders and Documentation Standards
Penalty
Summary
The deficiency involves failures in medication administration and documentation that did not meet professional standards or comply with facility policy. For one resident with hypertension, hyperlipidemia, and moderate cognitive impairment, the facility’s records included staff statements indicating that a nurse administered omeprazole, an antacid medication, to this resident even though it was intended for another resident. Another nurse documented that the resident reported being given an antacid pill and refusing a thyroid pill because they were not on that medication. These events show that the resident received a medication without a valid physician’s order and that the nurse did not correctly identify the resident before administering the drug, contrary to the facility’s policy requiring use of two identifiers and adherence to the six rights of medication administration, including right resident and right drug. A second deficiency involved another resident who was admitted with multiple serious diagnoses, including traumatic subdural hemorrhage, history of falling, protein-calorie malnutrition, lung cancer, and secondary malignant neoplasm of the cerebral meninges, and who was non-verbal. The physician’s order dated 2/14/26 directed that ondansetron 8 mg be given via G-tube every 8 hours as needed (PRN) for nausea or vomiting. This order was transcribed to the resident’s MAR as a PRN medication, and the MAR showed a PRN entry on 2/18/26. Progress notes documented that the resident vomited after a bolus feeding on one shift and had another vomiting episode at 6:20 AM on a later date. Further review of the medical record showed that there was no documentation that PRN ondansetron was administered at the times when vomiting or nausea were documented, nor was there documentation explaining why the medication was not given when the resident had nausea or vomiting. Additionally, progress notes recorded that ondansetron was administered on two separate occasions with positive effect, but there was no corresponding documentation on the MAR to show that the PRN medication had been signed out as given. These omissions conflicted with the facility’s medication administration policy, which requires that medications be administered as ordered by the physician and that the MAR be reviewed to identify the medication and signed after administration.
Incomplete Documentation of Private Aide Education and Foley Catheter Event
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records and documentation for two residents. For the first resident, who had multiple fractures, lack of coordination, cognitive impairment with a BIMS score of 9/15, and required substantial/maximal assistance with transfers, the facility allowed a private aide to be present without documented education on the resident’s care needs or limitations. The resident’s baseline care plan required one-person assistance for all ADLs, and the comprehensive care plan identified the resident as a fall risk with a prior fall and right shoulder fracture. On the night of the incident, the private aide reported to the RN that the resident fell at approximately 4:15 AM, was found standing at the foot of the bed, slid onto the floor mat, and was then picked up and placed back in bed by the aide without calling staff for assistance. Although nursing staff and the DON stated that private aides were verbally instructed not to provide hands-on care and to use the call bell for assistance, there was no documentation in the medical record that this private aide was educated on the resident’s required level of care or that the aide understood these instructions. For the second resident, who had encephalopathy, dementia with a BIMS score of 4/15, urinary retention, diarrhea, and Non-Hodgkin lymphoma, and who had an indwelling urinary catheter, the facility failed to document a complete assessment when the resident’s Foley catheter became dislodged. The resident’s care plan included monitoring vital signs, labs, and diagnostics as ordered by the physician. A change in condition progress note created by an RN documented that the Foley catheter had dislodged and that the physician was to be notified as necessary, but the note did not include any documentation that vital signs were taken or that pain was assessed at the time of the event. The DON later stated that when a Foley catheter becomes dislodged, the nurse should assess the site, obtain vital signs, and assess for pain, and that this information should be documented in the progress notes so that everyone is aware of the resident’s status. Additional facility policies required that private duty services support resident safety and community standards, and that all services provided to residents, including treatments, services performed, and changes in condition, be completely and accurately documented. The facility’s vital signs policy required that vital signs be taken at clinically appropriate intervals and when there were changes in a resident’s condition. Despite these policies, there was no documented evidence that the private aide for the first resident was educated on the resident’s care needs and restrictions, and there was no documentation in the second resident’s medical record that vital signs and pain were assessed and recorded when the Foley catheter became dislodged, even though an electronic communication later indicated that vital signs were at baseline and no signs of bleeding or trauma were observed. These omissions resulted in incomplete medical records for both residents.
Failure to Promptly Communicate Critical Lab Results Leading to Delayed Hospital Transfer
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s critical laboratory results were promptly and effectively communicated to the attending physician, resulting in a three‑day delay in physician notification and subsequent transfer to the hospital. The resident had multiple significant diagnoses, including acute respiratory failure, heart failure, COPD, type 2 diabetes, and a history of low platelet counts, and had recently completed antibiotics for pneumonia. The resident’s care plan identified risk for bleeding and bruising related to Plavix use, with an intervention to obtain labs as ordered and report abnormal results to the physician as soon as possible. Weekly CBC and BMP labs were ordered, and on 12/8 the resident’s platelets were already low at 59 K/CU.MM, with the physician’s subsequent progress notes referencing trending labs. On 12/15, a CBC and BMP were collected and later reported with critical abnormalities, including a platelet count of 20 K/CU.MM, elevated creatinine of 1.99 mg/dl, sodium of 130 mmol/L, and an eGFR of 27. A nursing progress note dated 12/16 documented that the lab called with critically low platelets (20) and that the physician was notified with no new orders, but the physician later stated he was not called about these labs at that time. Instead, the overnight LPN sent a text message to the physician around 1:28 AM reporting the critical platelet count and asking for orders, and then sent a second text at 5:26 AM about another resident’s dark red urine. The physician responded at 6:23 AM with two brief texts, “Noted” and “Hold Eliquis,” which he and the facility later clarified were in response to the second resident’s issue; he stated he never saw the earlier text about the critical platelet count, and no direct voice communication occurred regarding the critical labs. Over the next two days, there was no documented direct physician notification or follow‑up regarding the critical platelet count and worsening renal function, and no new orders were obtained based on those results. The overnight LPN reported that she assumed the physician’s text responses applied to both residents and endorsed to day shift that the critical labs had been communicated and that there were no new orders, expecting the physician to see the resident. The physician later confirmed that he only became aware of the critical labs when a unit manager called him on 12/18 after the resident’s responsible party questioned the lab results and lack of physician contact during a care plan meeting. Upon reviewing the labs at that time, the physician instructed that the resident be sent to the ER for evaluation due to the drop in platelet count and abnormal blood counts. The resident was transferred with the stated reason of a drop in platelet count and was subsequently admitted to the hospital with septic shock and pneumonia. Facility leadership, the physician, the medical director, and multiple nurses acknowledged that critical labs were expected to be communicated emergently by direct phone call, not solely by text, and that in this case there was a delay in care and treatment due to the failure to promptly and effectively notify the physician of the critical results. Interviews with the physician, medical director, DON, ADON/IP, and nursing staff further established that facility policy and expectations required direct voice communication for critical results, with escalation to the medical director if the attending physician did not respond within a specified time. The physician stated that critical labs must be called in emergently and that, had he been made aware immediately, he would at least have considered additional lab surveillance, escalation of care, or hospital evaluation. After later reviewing the chart, he noted that the substantial decline in renal function, which was not included in the initial text, would also have prompted emergency intervention. The medical director reported that he had previously educated staff that critical results, including labs, radiology, and ultrasounds, must be communicated by phone rather than text because texts are short and can create confusion. The facility’s own policies on lab/diagnostic results and acute condition changes required prompt physician notification, direct voice communication for urgent results, and contacting the medical director if the attending physician did not respond, but these standards were not followed in the handling of this resident’s critical laboratory findings. The resident’s responsible party reported learning during a care plan meeting that lab results had been available for three days without a physician call, and the physician confirmed he had not been notified until contacted by the unit manager on the day of transfer. The LNHA later stated he could not locate a formal investigation specific to the critical lab delay, while the ADON/IP stated she had reviewed the medical record and text messages as part of a review of acute discharges and acknowledged a delay in care. The DON also acknowledged a delay in treatment. Overall, the sequence of events shows that the facility did not ensure that critical lab results obtained on 12/15 were immediately and effectively conveyed to the physician, contrary to professional standards of practice, facility policy, and the resident’s care plan interventions, resulting in a three‑day delay in physician notification and transfer for evaluation and treatment.
Failure to Promptly Notify Practitioner of Abnormal Urine Culture Result
Penalty
Summary
The deficiency involves the facility’s failure to promptly notify a practitioner of an abnormal urine culture result and to follow its own lab notification policy for one resident. The resident was admitted with diagnoses including acute kidney failure, diabetes, and a urinary tract infection, and had a BIMS score of 6/15, indicating severely impaired cognition. A urine culture collected on 11/12/2025 was reported to the facility on 11/14/2025 at 1:49 PM as abnormal. However, progress notes show that antibiotic therapy was not ordered until 11/18/2025, when a nurse practitioner reviewed the urine culture results and initiated treatment. Interviews with the UM/LPN, DON, Regional Nurse, and the nurse practitioner established that facility expectations and policy required nurses to promptly notify the practitioner of abnormal lab results once received. The UM/LPN stated that a four-day delay in notifying the provider of an abnormal lab result would be considered a delay in care and acknowledged that policy was not followed for this resident. The DON and Regional Nurse confirmed that although clinicians can access lab results in the electronic system, nurses are expected to alert them when abnormal results are received, and that lack of notification and documentation means the policy was not followed. The nurse practitioner caring for the resident stated that the provider should have been notified on the date the abnormal result was reported and confirmed that the delay constituted a delay in care.
Improper Use of Sheet as Physical Restraint During Mealtime
Penalty
Summary
The deficiency involves the use of a physical restraint on a resident with severely impaired cognition, behaviors, and an underlying C-diff infection, in a manner that was for staff convenience and not required to treat a medical symptom. The facility’s own restraint policy stated that restraints were to be used only for the safety and well-being of residents, only after other alternatives had been tried unsuccessfully, and never for discipline, staff convenience, or fall prevention. Physical restraints were defined in the policy as any manual method or device attached or adjacent to the resident’s body that the individual cannot remove easily and that restricts freedom of movement or normal access to one’s body. The resident had dementia, dysphagia, anxiety disorders, and osteoporosis, and an MDS assessment showed a BIMS score of 0/15, indicating severely impaired cognition. The care plan documented impaired cognitive function related to dementia and behavior issues including grabbing, pushing, putting small objects in the mouth, removing briefs and leaving them anywhere, and removing an ace bandage from the left lower extremity. The resident was also on antibiotics and had C-diff, with care plan interventions including contact isolation, use of gowns and masks when changing contaminated linens, disinfection of equipment, and education of resident, family, and staff regarding infection prevention. Additional care plan entries indicated the resident required contact precautions related to C-diff, including disposal of soiled products per policy, placement in a private room, assistance with position changes, and appropriate handwashing. On the evening of the incident, a CNA reported having been told that the resident was on isolation precautions for C-diff and had behaviors of taking off clothes and briefs. Around dinner time, the CNA served the resident’s meal and placed a sheet on the resident’s lap to prevent the resident from tampering with their brief or removing their pants during mealtime. The CNA stated that the sheet repeatedly fell to the floor and, due to concern that the resident, who ambulated impulsively, could trip or fall on the sheet, the CNA loosely tied the sheet around the resident’s waist and behind the wheelchair. Later that evening, the resident’s family member entered the room, found the resident alone in a wheelchair with the dinner tray in front, and discovered a white bed sheet wrapped around the resident’s waist and tied behind the wheelchair. When notified, the nursing supervisor observed the resident sitting upright in the wheelchair with the sheet over the lap and loosely secured behind the back, with no staff present in the room, and then removed the sheet. This use of a tied sheet around the resident’s waist and wheelchair constituted a physical restraint imposed for care convenience and not required to treat the resident’s medical symptoms, leading to an Immediate Jeopardy determination beginning at the time the sheet was applied during dinner.
Removal Plan
- Certified Nursing Assistant (CNA) #1 was immediately removed from resident care and suspended pending investigation.
- Nursing staff conducted an immediate comprehensive head-to-toe physical, skin, and neurological assessment, with no injuries identified.
- The resident's primary medical provider was notified.
- Responsible parties present in facility were notified.
- The NJDOH and Office of the Ombudsman were notified.
- Ongoing monitoring orders were initiated for three (3) consecutive days.
- All residents with a Brief Interview for Mental Status (BIMS) score of 11 or less received precautionary skin checks.
- All residents with BIMS score of 12 or higher were interviewed and denied witnessing or experiencing any abuse or concerning behavior related to CNA #1's assignment.
- Written statements were obtained from all staff involved.
- A full-house in-service training was initiated for all staff with emphasis on CMS F604 (Freedom from Abuse, Neglect, and Exploitation).
- Education reinforced that no improvised devices, linens, or methods may be used in any manner that could be perceived as restrictive, regardless of intent.
- Staff were re-educated on the requirement that only approved, care planned, and policy compliant interventions may be utilized at all times.
Failure to Maintain Required Full-Time Social Worker Coverage in a Large Facility
Penalty
Summary
The facility failed to employ a qualified full-time Social Worker (SW) despite being licensed for 180 beds, which exceeds the 120-bed threshold requiring a full-time SW under CMS guidelines implemented on 11/28/17 and N.J.A.C. 8:39-39.3(a); 39.2. During the survey entrance conference, the Licensed Nursing Home Administrator (LNHA) stated that the facility did not have a full-time SW and that the part-time SW had left approximately two weeks earlier. The Human Resources Director (HRD) later confirmed that the facility had no full-time SW for the last five months and that, after the full-time SW left, a part-time or per diem SW worked up to 30 hours per week before also leaving two weeks prior to the survey. The LNHA reviewed a Director of Social Work job posting dated 08/16/2024 with the surveyor and stated that it was around that time the facility lost its full-time SW, acknowledging that the facility should have a full-time SW to meet residents' needs. Timecard records for the SW showed minimal hours worked in successive pay periods from mid-November 2025 through late January 2026, with hours ranging from 4.25 to 8.92 per pay period, demonstrating that social work coverage was far below full-time. The facility’s own SW job description specified that the position’s primary purpose was to assist in planning, organizing, and developing the Social Services Department to ensure that residents’ medically related emotional and social needs were met on an individual basis, underscoring the gap created by the absence of a full-time SW.
Failure to Provide Needed Social Services, Abuse-Related Support, and Discharge Planning
Penalty
Summary
The deficiency involves the facility’s failure to provide medically related social services to residents who required assistance with outside services and psychosocial support. Resident council minutes from late 2025 showed residents asking when a social worker would be available, and later notes indicated that a part‑time social worker was only in the facility a few days a week, with the LNHA, DON, and ADON expected to help if residents needed anything. At the time of survey, the LNHA reported that the part‑time social worker had left about two weeks earlier and that there was no current social worker in place, despite the facility’s own job description stating that the social worker is responsible for ensuring residents’ medically related emotional and social needs are met. One resident with dementia, muscle weakness, and dependence on staff for transfers reported back pain and requested to return to bed. An insurance case worker later reported that a CNA had been rough with this resident during the transfer, and the CNA was suspended pending investigation. Facility policy required that, when abuse is reported, the LNHA or designee request that social services monitor the resident’s psychosocial status in response to the incident and investigation. However, the documentation related to this incident did not show that social services monitored the resident’s psychosocial status, and the LNHA confirmed that the resident was not seen by social services after the abuse allegation. Another resident with intact cognition, multiple complications of Type 1 diabetes, an amputation, and generalized weakness had expressed a desire to leave the facility and live in the community. This resident requested assistance from a social worker for obtaining a phone and community housing and reported having asked for such help since September 2025. A grievance documented that the Regional Admissions Director, rather than social services, met with the resident and provided some contact information, but the resident stated that the corporate social worker gave incorrect resource information and forms the resident could not complete due to neuropathy, and the resident was not comfortable having other staff complete them. A third resident, also cognitively intact and with significant medical conditions and a stated goal of community discharge, reported that the discharge process was difficult and that they could not speak to the proper people to arrange discharge. The resident’s family member stated there was no meeting with family or discussion with a social worker about discharge, and that family had to handle most discharge arrangements, while no social services progress notes related to discharge planning were provided.
Failure to Clearly Update Care Plan After Abuse Allegation
Penalty
Summary
The facility failed to update the care plan with a clear focus, goals, and interventions for a resident involved in a staff-to-resident abuse allegation. The resident had diagnoses including other lack of coordination, muscle weakness, need for assistance with personal care, and unspecified dementia without behavioral, psychotic, mood, or anxiety disturbances. A quarterly MDS showed a BIMS score of 9/15, indicating moderately impaired cognition, and documented that the resident was dependent on a helper for transfers from sitting to standing and from chair to bed. Progress notes indicated that the resident complained of back pain and requested to be returned to bed, and staff assisted the resident back to bed. An undated facility document showed that an insurance case worker reported that a CNA was rough with the resident during the transfer to bed and that the resident was saying "ow" during the transfer. The CNA was suspended pending investigation, and the allegation of rough handling was later determined to be unsubstantiated. Review of the resident’s care plan revealed a focus labeled "Documented Resident/Representative Concerns" initiated on the same date as the incident, with interventions limited to the nurse identifying the area of concern, notifying appropriate department leaders per protocol, and notifying Social Services of the concern and possible need for a care conference. The Unit Manager stated that after an abuse allegation, the resident’s care plan should be updated so staff know that allegations were made and what to do, and that he or the DON typically updated care plans. The Regional DON stated that the care plan update for this resident did not meet her expectations and that the issue being addressed was not clear, which did not align with the facility’s policy requiring individualized care plans with measurable objectives and revisions as the resident’s condition dictates.
Incomplete Facility Assessment of Behavioral and Mental Health Needs and Resources
Penalty
Summary
The deficiency involves the facility’s failure to develop and maintain a comprehensive facility assessment (FA) that accurately identified the mental and behavioral health needs of its resident population and the resources necessary to provide appropriate care. On 2/11/26, a surveyor requested and reviewed the FA dated 7/22/25, which stated its purpose was to determine what resources were necessary to care for residents competently during day-to-day operations and emergencies. The FA’s scope referenced resident population characteristics, including physical and behavioral health needs, and required staff competencies, as well as facility resources such as behavioral health services and contracted personnel. Upon review, the FA listed certain psychiatric and mood disorders (schizophrenia, depression, anxiety) under diseases/conditions and referenced a vendor retained to provide psychiatric and psychological services, as well as behavioral and mental health services such as psychological, psychiatric, and PESS (Psychiatric Emergency Screening Services) unit. However, the FA did not identify the contracted mental health professional under Social Services, and none of the behavioral and mental health providers (psychiatrists, psychologists, licensed counselors) were named; the areas to identify these providers were left blank. Under staffing patterns for behavioral health services, the FA stated that staffing was adequate for residents with dementia, mental health conditions, or a history of trauma, but no evidence or supporting information was documented. During an interview with the LNHA, DON, and DOO, the surveyor asked them to identify where psychiatric and behavioral issues were addressed in the FA. The LNHA pointed to the sections referencing behavioral and mental health services and the contracted mental health professional but acknowledged that information for mental health providers was not available and that no evidence was listed under behavioral health staffing patterns. When asked if the FA reviewed was fully complete, the DON stated it was not, and confirmed that the facility had a large population of residents with mental health, behavioral, and psychiatric issues. Both the LNHA and DON acknowledged that several necessary components of the FA were missing, and the LNHA stated she had attempted to review the FA but had not had the chance to do so. The facility’s own policy required a comprehensive, documented facility-wide assessment addressing resident population needs, including physical and behavioral health, staffing competencies, services (including behavioral health), and shift-specific staffing, to be reviewed and updated at least annually, which was not met in this instance.
Some of the Latest Corrective Actions taken by Facilities in New Jersey
- Re-educated dietary staff on proper dish machine and three-compartment sink use to ensure washing, rinsing, and sanitizing were completed in the correct order with proper temperatures and sanitizing (L - F0812 - NJ)
- Re-educated dietary staff on documenting sanitizer test results with each use on flow sheets to support ongoing monitoring of sanitizer effectiveness (L - F0812 - NJ)
- Completed return demonstrations/competencies for pot washers with observation by the LNHA and interim FSD to verify correct dishwashing and sanitizing practices (L - F0812 - NJ)
- Required all dietary staff to complete re-education, competencies, and return demonstrations prior to working to ensure staff demonstrated correct sanitation practices before independent assignment (L - F0812 - NJ)
- Posted English and Spanish instructional signage by the dish machine and three-compartment sink to reinforce correct sanitizer use (L - F0812 - NJ)
Improper Dishwashing and Sanitizer Monitoring Leading to Immediate Jeopardy
Penalty
Summary
The deficiency involves the facility’s failure to ensure that dishwashing equipment and manual warewashing processes were maintained and operated according to manufacturer specifications and facility policy, resulting in improper sanitation of dishware, cookware, and utensils. Surveyors found that the dish machine’s hot water booster had not been functioning since a snowstorm, and the machine had been converted by the vendor from a high‑temperature to a low‑temperature chemical sanitizing system. Despite this change, there was no evidence that staff were monitoring or documenting dish machine temperatures or chemical sanitizer concentrations. The last recorded entry on the dish machine temperature log was dated 12/31/25, and the acting Food Service Director (FSD) could not demonstrate how to check or interpret chemical concentrations, nor locate appropriate test strips. The dish machine vendor later informed the facility that the chemical sanitizer attached to the dish machine was expired and not properly sanitizing dishware. Surveyors also observed significant deficiencies in the use of the three‑compartment sink for manual warewashing. A dietary staff member was seen washing pots and pans in the first sink and then placing them directly into the third sink containing sanitizer, skipping the required rinse step in the second sink. The staff member stated, "I don't check for anything" and was unable to explain the correct setup or process for the three‑compartment sink. There was no log documenting sanitizer concentration checks for the three‑compartment sink, and the acting FSD could not initially locate test strips or provide policies beyond a poster above the sink. When the acting FSD attempted to test the sanitizer in the three‑compartment sink, she first used chlorine test strips incorrectly (wrong contact time and no color change), then later used the correct quaternary test paper and obtained a reading between 200–400 ppm, but still reported there was no documentation system in place. During meal service observations, surveyors noted that most residents were being served meals on disposable dishware and utensils, while some residents continued to receive meals on regular washable dishware and utensils. On two nursing units, breakfast trays included both disposable and regular dishware, and used meal trays in the hallway contained a mix of ceramic and disposable items. The acting FSD stated that disposable dishware was being used for most residents because the dish machine was not reaching the required sanitizing temperature, but that two residents who refused disposables continued to receive meals on regular dishware and washable utensils. Nursing staff on the units could not explain why disposables were being used and deferred questions to kitchen staff. The LNHA gave conflicting explanations, at one point stating the dish machine had been working and disposables were used due to an influx of evacuated residents, and at another point acknowledging that the machine had been converted to low‑temperature chemical sanitizing. The LNHA was not aware that sanitizer levels needed to be monitored with the low‑temperature setup, and neither he nor dietary staff could provide documentation that sanitizer concentrations were being checked or recorded. These combined failures in equipment maintenance, monitoring, staff competency, and adherence to written policies led to an Immediate Jeopardy determination related to food safety and sanitation for all residents. The facility’s written policies required specific wash and final rinse temperatures for high‑temperature dishwashers and specified sanitizer concentration requirements for low‑temperature dishwashers, but there was no policy guidance on converting from high‑temperature to low‑temperature chemical sanitization when the booster failed. The dish machine failure policy directed the use of disposables when the dishwasher was out of service, but did not address monitoring of chemical sanitizers or procedures for a low‑temperature system. The Safety Data Sheet for the low‑temperature sanitizer attached to the dish machine described it as a hazardous chemical capable of causing eye and skin burns, respiratory irritation, and harm if swallowed, underscoring the need for correct use and monitoring. Despite this, staff were unable to demonstrate proper testing of sanitizer concentrations, did not maintain logs, and in at least one instance did not follow the manufacturer’s required wash‑rinse‑sanitize sequence in the three‑compartment sink. These documented observations and interviews formed the basis of the cited deficiency for failure to procure, prepare, and serve food under sanitary conditions and in accordance with professional standards.
Removal Plan
- The LNHA contacted the dish machine vendor.
- The LNHA re-educated the Cook, dietary cooks, and dietary aides regarding kitchen sanitation to ensure proper handling of pots, pans, cutlery, and dishware.
- The LNHA re-educated dietary staff on proper use of the dish machine and the three-compartment sink to ensure washing, rinsing, and sanitizing are done correctly, in the correct order, with proper temperatures and sanitizing.
- The LNHA re-educated dietary staff on the importance of documenting sanitizer test results on flow sheets with each use.
- Return demonstrations/competencies were completed by the pot washers and observed by the LNHA and interim FSD.
- All dietary staff will be re-educated and required to complete competencies and return demonstrations prior to working.
- The LNHA re-educated the Cook and dietary staff regarding the use of disposables/paper goods in the event the dishwasher is out of service.
- All necessary dishware was immediately re-sanitized.
- Signs in English and Spanish with instructions for sanitizer use were posted by the dish machine and three-compartment sink.
Improper Use of Sheet as Physical Restraint During Mealtime
Penalty
Summary
The deficiency involves the use of a physical restraint on a resident with severely impaired cognition, behaviors, and an underlying C-diff infection, in a manner that was for staff convenience and not required to treat a medical symptom. The facility’s own restraint policy stated that restraints were to be used only for the safety and well-being of residents, only after other alternatives had been tried unsuccessfully, and never for discipline, staff convenience, or fall prevention. Physical restraints were defined in the policy as any manual method or device attached or adjacent to the resident’s body that the individual cannot remove easily and that restricts freedom of movement or normal access to one’s body. The resident had dementia, dysphagia, anxiety disorders, and osteoporosis, and an MDS assessment showed a BIMS score of 0/15, indicating severely impaired cognition. The care plan documented impaired cognitive function related to dementia and behavior issues including grabbing, pushing, putting small objects in the mouth, removing briefs and leaving them anywhere, and removing an ace bandage from the left lower extremity. The resident was also on antibiotics and had C-diff, with care plan interventions including contact isolation, use of gowns and masks when changing contaminated linens, disinfection of equipment, and education of resident, family, and staff regarding infection prevention. Additional care plan entries indicated the resident required contact precautions related to C-diff, including disposal of soiled products per policy, placement in a private room, assistance with position changes, and appropriate handwashing. On the evening of the incident, a CNA reported having been told that the resident was on isolation precautions for C-diff and had behaviors of taking off clothes and briefs. Around dinner time, the CNA served the resident’s meal and placed a sheet on the resident’s lap to prevent the resident from tampering with their brief or removing their pants during mealtime. The CNA stated that the sheet repeatedly fell to the floor and, due to concern that the resident, who ambulated impulsively, could trip or fall on the sheet, the CNA loosely tied the sheet around the resident’s waist and behind the wheelchair. Later that evening, the resident’s family member entered the room, found the resident alone in a wheelchair with the dinner tray in front, and discovered a white bed sheet wrapped around the resident’s waist and tied behind the wheelchair. When notified, the nursing supervisor observed the resident sitting upright in the wheelchair with the sheet over the lap and loosely secured behind the back, with no staff present in the room, and then removed the sheet. This use of a tied sheet around the resident’s waist and wheelchair constituted a physical restraint imposed for care convenience and not required to treat the resident’s medical symptoms, leading to an Immediate Jeopardy determination beginning at the time the sheet was applied during dinner.
Removal Plan
- Certified Nursing Assistant (CNA) #1 was immediately removed from resident care and suspended pending investigation.
- Nursing staff conducted an immediate comprehensive head-to-toe physical, skin, and neurological assessment, with no injuries identified.
- The resident's primary medical provider was notified.
- Responsible parties present in facility were notified.
- The NJDOH and Office of the Ombudsman were notified.
- Ongoing monitoring orders were initiated for three (3) consecutive days.
- All residents with a Brief Interview for Mental Status (BIMS) score of 11 or less received precautionary skin checks.
- All residents with BIMS score of 12 or higher were interviewed and denied witnessing or experiencing any abuse or concerning behavior related to CNA #1's assignment.
- Written statements were obtained from all staff involved.
- A full-house in-service training was initiated for all staff with emphasis on CMS F604 (Freedom from Abuse, Neglect, and Exploitation).
- Education reinforced that no improvised devices, linens, or methods may be used in any manner that could be perceived as restrictive, regardless of intent.
- Staff were re-educated on the requirement that only approved, care planned, and policy compliant interventions may be utilized at all times.
Significant Medication Error from Incorrect Medication Reconciliation
Penalty
Summary
The deficiency involves a failure to ensure that a resident was free from significant medication errors during the admission and medication reconciliation process. A resident identified as having diagnoses including influenza, depression, cerebral infarction, hyperlipidemia, hypertension, and cardiac arrhythmia was admitted to the facility. An LPN/Unit Manager (LPN/UM) was responsible for reviewing the admission packet and reconciling the resident’s medications. While transcribing the medication list, which was on multiple pages, the LPN/UM did not verify that each page belonged to the correct resident and mistakenly used another resident’s medication list. As a result, medications prescribed for a different resident were entered into this resident’s electronic medical record and medication administration record (MAR). Review of the January MAR and order summary report for the admitted resident showed that several medications not ordered for this resident by the transferring facility were listed and administered. These included furosemide 20 mg daily, lithium carbonate ER 450 mg daily, trazodone 100 mg at bedtime, clonazepam 0.5 mg twice daily, and risperidone 3 mg twice daily. The transferring facility’s medication list for this resident did not contain any of these medications. Further review of records showed that these medications actually belonged to another resident with diagnoses including schizoaffective disorder, heart failure, and hypertension. The LPN/UM’s written statement confirmed that she failed to verify that each page of the multi-page medication list was for the correct resident, which led to entering the wrong medications and providing inaccurate information to the provider when obtaining verbal orders. The MAR documented that the wrong medications were administered over multiple days. Clonazepam and risperidone were given starting on the day of admission and continued on subsequent days; trazodone was administered at bedtime on several consecutive nights; and furosemide and lithium were administered daily on multiple mornings. The error was discovered only after the resident’s representative informed facility staff that the medications on the list were not accurate and reported that the resident was not completing sentences. The facility’s investigation, interviews with staff, and review of the medical record confirmed that the medication reconciliation process was not performed correctly, that the LPN/UM used another resident’s medication list, and that the attending physician had been provided with incorrect medication information when admission orders were obtained.
Removal Plan
- Assess and monitor the resident for any adverse reaction, including vital signs and level of consciousness; initiate and maintain neurological checks until the resident is sent out for further evaluation.
- Initiate an investigation into the incident and suspend the identified LPN/UM pending the outcome of the investigation.
- Audit all new admissions and re-admissions (including discharged medication reconciliation records) to ensure accuracy, proper transcription, physician orders, and compliance with the facility's admission protocol.
- Provide re-education for licensed nursing staff on the facility's admission process, medication reconciliation requirements, nurse accountability, and resident identification procedures.
- Educate licensed nursing staff on a protocol requiring two-nurse verification for transcription and review of hospital discharge medication lists and use of two resident identifiers prior to medication transcription and administration.
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