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 facility failed to include discharge planning in the care plans of six residents whose diagnoses included CKD, CHF, DM2, dementia, PTSD, epilepsy, metabolic encephalopathy, secondary parkinsonism, AFib, and hyperlipidemia. The DSW stated discharge planning was discussed during assessments but was not added as a care plan focus, and the DON stated discharge planning should be part of each resident’s person-centered care plan.
Improper Release of Resident Information: A resident with severe cognitive impairment and diagnoses including metabolic encephalopathy, secondary parkinsonism, and dementia had personal contact information included in the admission record. The LNHA contacted an outside facility, shared the resident’s information, and asked that facility to reach out to the resident’s family without first obtaining permission from the family, and without documentation showing the family knew the outside facility was being contacted. The LNHA later stated he had not completely followed the facility’s Release of Information policy.
Unsafe and Unclean Resident Environment: A resident was observed in bed with an emptied, needleless saline syringe left on top of the blanket, and a soiled paper towel was found inside a drawer outside a room that contained PPE gowns. The LNHA stated that saline syringes should not be left in a resident’s bed. The facility policy requires a clean, sanitary, and orderly environment.
Improper Physical Restraint Used During Respiratory Treatment: An RN secured a resident’s left hand to the side rail with a pillowcase while attempting to administer a nebulizer treatment after the resident became combative and removed the mask. The resident had dementia, severe cognitive impairment, respiratory failure, and functional quadriplegia, and the restraint was later observed by the hospice nurse and confirmed in the facility’s event investigation.
A resident with hemiplegia, severe cognitive impairment, a feeding tube, and surgical wounds was ordered EBP for a PEG tube, but the care plan did not include the EBP need or related interventions. The DON confirmed the omission and stated that the care plan is meant to communicate interventions for resident safety, protection, and care.
Incomplete Care Planning for Double Incontinence Brief Use: Two residents were observed wearing two incontinence briefs, and staff confirmed the residents had requested this practice. One resident had diagnoses including amputation, DM2, and repeated falls; the other had rhabdomyolysis, DM2, sepsis, and UTI and was incontinent of bowel and bladder, chairfast, and severely limited in walking. Staff stated the nurse was not informed before the briefs were applied, and the residents’ care plans were updated after the surveyor’s observations.
Missing Discharge Planning in Care Plans
Penalty
Summary
The facility failed to develop a comprehensive care plan to address residents’ discharge plans for six residents reviewed. Resident #1 was admitted with chronic kidney disease, hypotension, and mild cognitive impairment, and Resident #2 was admitted with congestive heart failure, type II diabetes, and dementia; neither resident’s care plan included a focus related to the resident’s preference and potential for future discharge. Resident #4 was admitted with type II diabetes, a cognitive communication deficit, and PTSD, and Resident #5 was admitted with epilepsy, type II diabetes, and hypertension; their care plans also did not include discharge planning as a focus area. Resident #6 was admitted with metabolic encephalopathy, secondary parkinsonism, and dementia, and Resident #7 was admitted with heart failure, atrial fibrillation, and hyperlipidemia; their care plans likewise did not address the resident’s preference and potential for future discharge. During interviews, the DSW stated that discharge planning was discussed during initial assessment and quarterly assessments, but she did not include discharge plans as a care plan focus area. The DON stated that discharge planning begins at admission and should be included in each resident’s care plan, and acknowledged she had seen one care plan that did not include it.
Improper Release of Resident Information
Penalty
Summary
The facility failed to keep a resident’s medical information confidential and did not follow its Release of Information policy. Resident #6 was admitted with diagnoses including metabolic encephalopathy, secondary parkinsonism, and dementia. The resident’s admission record contained the resident’s address and the addresses and phone numbers of two contacts. The resident’s comprehensive MDS dated 4/21/26 showed a BIMS score of 5 out of 15, indicating severely impaired cognition, and the care plan did not include a focus related to the resident’s preference and potential for future discharge from the facility. An investigation summary provided by the DON stated that the facility received an allegation that it improperly released Resident #6’s contact information to an outside facility. The document confirmed that the facility contacted an outside third-party facility, provided Resident #6’s information, and asked that facility to contact the resident’s family without first obtaining permission from the family. During interview, the LNHA confirmed that he identified and contacted the outside facility, sent a referral in preparation for discharge, did not discuss this with Resident #6 because of the resident’s low cognition, and did not reach out to the family. No documentation was provided showing that the family knew the outside facility was being contacted. The LNHA later reviewed the Release of Information policy and stated that he had not completely followed it.
Unsafe and Unclean Resident Environment
Penalty
Summary
The facility failed to provide a safe, clean, and homelike environment for Resident #119 and for one of four floors observed during the environmental task. During the initial tour on 05/21/2026 at 10:28 AM, the surveyor observed Resident #119 in bed with an emptied, needleless saline syringe left on top of the resident’s blanket. Later that same tour, at 10:38 AM, the surveyor observed a plastic drawer outside of room [ROOM NUMBER] with a soiled paper towel inside the top drawer that contained personal protective gowns. During an interview on 05/28/2026 at 1:09 PM, the LNHA stated that saline syringes should not be left in a resident’s bed. The facility policy titled, Quality of Life - Homelike Environment, revised 01/2026, states that staff and management shall maximize characteristics of the facility that reflect a personalized, homelike setting, including a clean, sanitary, and orderly environment.
Improper Physical Restraint Used During Respiratory Treatment
Penalty
Summary
The facility failed to keep a resident free from the use of a physical restraint when RN#1 used a pillowcase to wrap around the resident’s left hand and tied it to the side rail during a nebulizer treatment. The resident was observed with the restraint by the hospice nurse, and the device was later removed by the Manager on Duty. The survey identified this as a deficiency involving 1 of 6 residents reviewed for restraint. The resident involved had diagnoses including unspecified dementia, major depression, respiratory failure, and functional quadriplegia. The resident’s MDS showed a BIMS score of 3 out of 15, indicating severely impaired cognition. The care plan identified the resident as resistive and combative with care related to cognitive loss/dementia, and the physician’s order summary included ipratropium-albuterol every 6 hours as needed for shortness of breath or wheezing. RN#1 stated the resident became combative and pulled off the nebulizer mask during the respiratory treatment, and she then secured the resident’s left hand to the side rail with a pillowcase to ensure the treatment was received. RN#1 later stated she should have called the medical doctor for refusal and documented the refusal. The facility reportable event and staff interview both confirmed that the resident’s left upper extremity had been secured to the enabler with a pillowcase during the treatment.
Failure to Include EBP for PEG Tube in Care Plan
Penalty
Summary
The facility failed to develop a care plan for a resident who was on enhanced barrier precautions related to a PEG tube. Resident #1 was admitted with diagnoses including hemiplegia affecting the nondominant side, need for gastrostomy care, and need for assistance with personal care. The resident’s MDS dated 04/10/2026 showed a BIMS score of 6 out of 15, indicating severe cognitive impairment, and also documented a feeding tube present on admission and surgical wounds. The Order Summary Report showed an order for enhanced barrier precautions related to the resident’s PEG tube, with an order date of 04/03/2026. Review of the resident’s care plans did not show a focus or interventions addressing the need for enhanced barrier precautions. During interview, the DON stated that the purpose of the care plan was to communicate appropriate interventions for resident safety, protection, and care, confirmed that the resident was on EBP because of the PEG tube, and acknowledged that the need for EBP was not included in the care plan.
Incomplete Care Planning for Double Incontinence Brief Use
Penalty
Summary
The facility failed to develop personalized care plans for 2 of 3 incontinent residents based on their preference for using two incontinence briefs. During incontinence rounds on the fourth floor, one resident was observed in bed with a small incontinence brief that was damp with urine inside an outer brief, and another resident was observed in bed wearing two incontinence briefs. Unit managers confirmed both residents were wearing two briefs at the time of the observations. One resident’s record showed diagnoses including aftercare following surgical amputation, acquired absence of the left leg below the knee, type 2 diabetes mellitus, need for assistance with personal care, and repeated falls. The care plan included a focus on risk for skin impairment and fragile skin, with interventions to provide incontinent care as needed and keep the skin clean and dry. It also included a focus on the resident’s preference for double diapers for comfort and dignity, with interventions to educate the resident on increased moisture retention, risk for skin breakdown, and discomfort, and to continue assessing the preference and discussing risks and benefits. The other resident’s record showed diagnoses including rhabdomyolysis, type 2 diabetes mellitus, sepsis, and urinary tract infection. The admission/readmission evaluation documented bowel and bladder incontinence, use of incontinence briefs, chairfast status, and severe limitation in walking. The care plan included a focus on potential skin impairment related to fragile skin, a focus on decreased ADL skills, and a focus on preference for double diaper use, with interventions to assess and document preferences, discuss risks and benefits, educate regarding skin breakdown, infection, and discomfort, and encourage use of one appropriately sized brief whenever possible. Staff interviews confirmed that the residents requested two briefs, that nurses were not informed before the briefs were applied, and that the use of two briefs had been added to the care plans after the surveyor’s incontinence rounds.
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Compliance trends in New Jersey
Data through Mar 2026Comparisons below measure the most recent period Apr 2025 – Mar 2026 against the prior period Apr 2024 – Mar 2025 (two equal 12-month windows). The most recent 2 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 2-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): Apr 2025 – Mar 2026 vs the prior period Apr 2024 – Mar 2025. Only tags with at least 20 citations in both periods are shown.
Severity movers
Tags whose average scope/severity shifted the most: Apr 2025 – Mar 2026 vs the prior period Apr 2024 – Mar 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: Apr 2025 – Mar 2026 vs the prior period Apr 2024 – Mar 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 Apr 2025 – Mar 2026 vs the prior period Apr 2024 – Mar 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 2 months are still being reported.
Deficiency-free survey rate
Share of health surveys that found zero deficiencies — the odds of a clean survey. Apr 2025 – Mar 2026 vs the prior period Apr 2024 – Mar 2025; the most recent 2 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 2 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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