Citations in New Jersey
Statistics, citations 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 resident with a PEG tube, dysphagia, dementia, epilepsy, and other neurologic conditions had scheduled meds ordered through the tube, but the eMAR showed no meds documented for an entire evening med pass. The RN/UM said she worked a double shift because of a nursing call-out and forgot to document the meds as given, and the DON acknowledged the missed documentation.
Failure to Report Injury of Unknown Origin: A resident with dementia, Parkinson's disease, and a prior traumatic subdural hemorrhage sustained an unwitnessed head injury after being seen trying to climb back into bed. Staff documented blood on the floor and the resident's head, and the resident was sent to the hospital. Although the injury was investigated and staff negligence was found unsubstantiated, the DON stated the event was not reported to the State Agency because it was not considered abuse or an injury of unknown origin, despite facility policy requiring immediate reporting of injuries from an unknown source.
A resident with dementia and severely impaired decision-making developed a facility-acquired skin impairment that progressed from MASD to an unstageable pressure ulcer/injury, but the resident's representative was not documented as being notified when the condition first appeared or when it worsened. Facility records showed the update to the representative occurred later, and staff interviews confirmed there was no note of earlier notification despite policy requiring notification of the resident/representative for changes in condition and new pressure ulcers.
A resident with dementia, metabolic encephalopathy, and severely impaired decision making was dependent for transfers and had therapy documentation indicating the need for a mechanical lift with two staff members. The care plan and EMR profile did not include the mechanical lift requirement, and a CNA transferred the resident from bed to a shower chair alone by lifting under the arms. The resident was later found to have a swollen, deformed left arm, and hospital imaging confirmed an acute displaced distal humerus fracture.
Failure to provide adequate supervision for a cognitively impaired resident with a high fall risk. The resident had severe cognitive impairment, hydrocephalus, restlessness, agitation, and difficulty walking, and required assistance with toileting and other ADLs. The resident had multiple unwitnessed falls and floor incidents, including being found on the floor in the room, in bathrooms, and in a hallway, with one event causing a head laceration and eyebrow hematoma. Staff notes and fall investigations showed the resident was impulsive, moved quickly, and at times was left unattended during toileting or was found away from the assigned room.
Dirty D Wing hallway floors were observed with dark brown areas throughout the corridor, including near the nurse’s station and around wet floor signs. A porter said the marks were deep and ground in, not removable by mopping, and that the area needed stripping and waxing. Leadership acknowledged D wing needed floor care, and the facility’s schedule showed incomplete documentation for D wing hallway stripping and waxing.
Missing Medication Documentation After Short-Staffed Shift
Penalty
Summary
The facility failed to provide sufficient nursing staff to ensure that medications and treatments were properly documented for one resident. Resident #47 had diagnoses including late effects of cerebral infarction, aphasia following cerebral infarction, dysphagia, dementia, epilepsy, hypertension, and gastrostomy status. The resident’s MDS indicated the resident was rarely or never understood and had a tube feeding. Physician orders included multiple scheduled medications administered via PEG tube and enteral feeding orders. Review of the eMAR for the evening shift showed no medications documented as administered for the entire medication pass. The medical record did not contain a nursing progress note explaining that the resident was out of the facility, refused medications, or otherwise accounting for the missing documentation. The RN/UM stated she worked a double shift because of a nursing call-out and, while working as the med nurse, forgot to document that the medications had been administered during the evening shift. The DON acknowledged that the RN/UM had worked two consecutive shifts due to a call-out and forgot to document administering the resident’s medications during the evening med pass.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to ensure that an allegation involving an injury of unknown origin was reported as required for one resident. The resident had diagnoses including traumatic subdural hemorrhage without loss of consciousness, Parkinson's disease, type 2 diabetes mellitus, and dementia, and the quarterly MDS showed a BIMS score of 8 out of 15, indicating moderate cognitive impairment. On 06/14/26, the resident was found in the room with an unwitnessed head injury after being observed attempting to climb back into bed. A CNA noted dried blood on the floor and on the left side of the resident's head, the fall protocol was initiated, and the resident was transferred to the local hospital for evaluation. The facility's internal investigation determined the allegation that staff negligence caused the injury was unsubstantiated and concluded the most likely scenario was an unwitnessed, self-initiated attempt by the resident to get out of bed and then re-enter independently, resulting in a loss of balance and head injury. The investigation documented a hematoma measuring approximately 4 cm x 3.6 cm on the left side of the head and stated the exact sequence of events could not be determined because the event was unwitnessed and the resident could not provide a reliable history. Despite this, the DON stated the facility did not report the incident because it was not considered abuse and was not identified as an injury of unknown origin requiring notification to the State Agency. The facility policy stated that injuries from an unknown source are to be reported immediately but not later than 2 hours after the injury has been reported.
Failure to Notify Resident Representative of Skin Condition Change
Penalty
Summary
The facility failed to notify the resident's representative of a change in condition for one resident who was admitted with diagnoses including dementia and hypertension and whose cognitive skills for daily decision making were severely impaired. The resident developed a facility-acquired skin impairment that was first noted as MASD to the sacral region and later evolved into an unstageable pressure ulcer/injury. The resident's progress notes did not include notification of the resident's representative when the new skin impairment was identified or when it changed to unstageable. The facility's own timeline showed that the new skin impairment was noted on 12/18/25 and that the resident's representative was not updated until 12/29/25. During interviews, an LPN stated that she thought the resident's representative would be notified when a resident had MASD, while the DON stated that a resident's representative would be notified if a resident had a new impairment, but she could not find documentation of notification for this resident. The facility policies reviewed stated that the resident's representative would be notified for changes in condition and that for a new pressure ulcer, the physician, resident/representative, and interdisciplinary team would be notified.
Improper Transfer Resulted in Humerus Fracture
Penalty
Summary
The facility failed to ensure that a resident who was dependent on staff for transfers was safely and properly transferred with two staff members via a mechanical lift. The resident had diagnoses including dementia, diabetes mellitus, metabolic encephalopathy, and peripheral vascular disease, and the MDS showed severely impaired decision making and dependence for tub/shower transfer. ADL change of status forms also indicated dependence for sitting to stand, chair/bed-to-chair transfer, toilet transfer, and tub/shower transfer. The resident’s therapy records documented that the resident was to be mechanically lifted due to safety concerns and was dependent and transferred via a mechanical lift. However, the individualized comprehensive care plan did not include a focus area for functional ability performance, and there were no interventions in place describing the type of assistance required for transfers before the incident. The DON acknowledged that the care plan did not include the requirement for a two-person mechanical lift transfer and stated this omission resulted from a communication error between rehabilitation therapy and nursing. On the day of the event, CNA #11 transferred the resident from bed to a shower chair by lifting the resident under the arms and pivoting the resident into the chair without obtaining assistance from another staff member. The CNA later observed that the resident’s left arm was swollen and deformed, and the resident was found to have pain, warmth, firmness, and grimacing with touch. Hospital imaging showed an acute comminuted displaced fracture of the distal left humerus. Interviews with nursing, therapy, and MDS staff confirmed that the resident required at least two staff members and that a mechanical lift should have been used, but the CNA stated she was unaware of that requirement because it was not included in the EMR care profile or care plan.
Failure to Provide Adequate Supervision for a High Fall-Risk Resident
Penalty
Summary
The facility failed to ensure adequate supervision for a resident with severe cognitive impairment and a high fall risk. The resident had diagnoses including hydrocephalus, mild cognitive impairment, restlessness and agitation, a history of TIA, and difficulty walking. The MDS assessment showed a BIMS score of 6 out of 15, indicating severe cognitive impairment, and the resident required substantial to maximal assistance with toileting hygiene and assistance with multiple other ADLs and transfers. The resident experienced multiple unwitnessed falls or floor incidents while in the facility. One incident occurred when the resident was found lying on the floor in the room and did not know what happened, resulting in a laceration to the left side of the head and a hematoma on the left eyebrow. Other incidents included being found sitting on the bathroom floor while trying to clean themself up, being found sitting on the floor in another room's bathroom, being found on the floor in the resident's own room, being found lying on the floor in a bathroom, and being found sitting on the floor in a hallway while grabbing handrails. The fall investigations and staff statements showed that the resident was impulsive, moved quickly, and required close monitoring, especially during toileting and bathroom use. One incident involved an aide leaving the resident unattended in the bathroom to retrieve clothing, and another involved the resident entering a room away from their own room and being found on the bathroom floor. The facility's own fall prevention policy stated that residents should be observed closely, kept occupied, and have needs anticipated to prevent falls, including placement in front of the nursing station and toileting supervision.
Dirty D Wing Hallway Floors
Penalty
Summary
The facility failed to maintain the D wing in a clean and sanitary condition. During multiple observations, surveyors saw dark brown areas on the D wing hallway floors, including throughout the hallways, in front of the nurse’s station, and around wet floor signs. On one observation, the floor around the wet floor sign had multiple dark brown areas, and on another, the hallway still showed the same dark brownish areas while a porter was buffing the floor. The porter stated the floors were mopped daily, but also said the marks were deep, ground in, and would not come up with mopping, and that the area in front of the nurse’s station needed stripping and waxing. He also stated the D wing hallway had not been stripped and waxed recently, while an area by the television had been done and appeared shinier and without stains. Facility leadership acknowledged that the housekeeping director had resigned about two to three months earlier and that D wing needed stripping and waxing. The AIT stated the facility had started with C wing because it was worse than D wing and that D wing was next. The LNHA initially stated stripping and waxing was done twice yearly and was due in May, but later the facility provided a schedule showing C wing hallways, A wing hallways, and C & D wing dayrooms, with D wing hallways listed without a date or signature. The hallway in front of the D wing nurse’s station was later observed to have been stripped and waxed over the weekend, and at that time it was shiny and without dark brown areas.
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Compliance trends in New Jersey
Data through Apr 2026Comparisons below measure the most recent period May 2025 – Apr 2026 against the prior period May 2024 – Apr 2025 (two equal 12-month windows). The most recent 3 months are excluded because CMS is still publishing them.
Top tags by month · last 24 months
dashed = still reportingMonthly citation counts for the 5 most-cited tags. The dashed tail is the 3-month reporting lag.
Frequency movers
Biggest change in how often each tag is cited, as a rate per 100 inspections (so it isn't skewed by survey volume): May 2025 – Apr 2026 vs the prior period May 2024 – Apr 2025. Only tags with at least 20 citations in both periods are shown.
Severity movers
Tags whose average scope/severity shifted the most: May 2025 – Apr 2026 vs the prior period May 2024 – Apr 2025. The number is the average severity on the A–L scale (A=0…L=11); the letter is the band it falls in. A rise means the same tag is being cited at a more serious level — note the average can move enough to rank here while staying within the same letter. Same 20-citation minimum applies.
Care domain movers
Citations grouped into CFR care domains — F-tags by their §483 regulatory section (CMS State Operations Manual, Appendix PP) — measured as a rate per 100 inspections: May 2025 – Apr 2026 vs the prior period May 2024 – Apr 2025. Share is the domain's portion of citations this period; avg severity is the mean scope/severity letter and immediate jeopardy the percentage cited at J–L, both over the current period. Domains with at least 20 citations in both periods are shown; the sparkline tracks the last 12 months (left = oldest).
Immediate jeopardies · this period
Citations at the most serious scope/severity — J–L, immediate jeopardy, residents placed at risk of serious harm or death — over May 2025 – Apr 2026 vs the prior period May 2024 – Apr 2025. "Surveys with an IJ" counts distinct health inspections that had at least one.
Survey activity · by month
faded/dashed = still reportingCitations each month split into complaint-driven (unscheduled, triggered by grievances) vs standard surveys — bars, left axis — with the number of inspections as a line on the right axis. Rising inspections signal more scrutiny; a rising complaint share means more off-cycle surveys. The most recent 3 months are still being reported.
Deficiency-free survey rate
Share of health surveys that found zero deficiencies — the odds of a clean survey. May 2025 – Apr 2026 vs the prior period May 2024 – Apr 2025; the most recent 3 months are still being reported (dashed).
Penalties · by month
faded = still reportingTotal civil money penalty dollars imposed on the state's facilities each month — how hard the state is enforcing. The most recent 3 months are still being reported, and penalties often lag citations by several months.
Emerging tags
Tags that weren't established last period but surged — an early warning, distinct from movers (which track already-common tags). Criteria: fewer than 20 citations in the prior period, but at least 10 this period and 2.5× their prior volume. The sparkline shows monthly counts over the last 12 months (left = oldest).
Trusted data from CMS and state health departments
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