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 resident with significant cognitive impairment and high fall risk was left unattended on a shower chair by a CNA who stepped out to retrieve a towel, resulting in the resident sliding off the chair and falling. The care plan required continuous supervision during bathing, but this was not followed, and staff interviews confirmed that residents should not be left alone during showers.
Surveyors found that the facility did not ensure proper documentation of ADL care for several residents, with missing entries in POC flowsheets for personal hygiene and toileting across multiple shifts. Residents affected had a range of cognitive and physical needs, and staff interviews confirmed that documentation was required but not consistently completed as per facility policy.
A resident with multiple medical conditions and a history of restlessness and prior elopement attempt was not properly assessed or care planned for elopement risk. Despite being identified as high risk, the resident's care plan and progress notes lacked elopement interventions, and conflicting documentation existed regarding their risk status. The resident exited the facility through a window without staff awareness, highlighting a failure to follow facility policy for elopement risk assessment and supervision.
The facility's assessment failed to identify and address the specific services, procedures, and resources required for ventilator-dependent residents. The assessment did not specify the facility's ventilator care bed licensing, nor did it include ventilator-dependent residents in sections covering diseases, care needs, staff training, or equipment. Leadership confirmed the omission during interviews, stating that ventilator care was considered under general respiratory needs.
A facility failed to implement a procedure for the safe acquisition and receipt of Methadone, a controlled substance, by assigning an unlicensed CNA to pick up and transport Methadone from an outside clinic for several residents. The CNA used a locked box and key, transported the medication in a personal vehicle, and delivered it to nursing staff, despite facility policy requiring controlled substances to be handled by a licensed nurse. Interviews confirmed the absence of a specific policy for this process.
An LPN administered IV antibiotics to two residents in error, giving each the other's prescribed medication due to failure to follow medication administration protocols, including the 5 Rights and required checks. One resident experienced an adverse drug reaction and required hospital admission, while the other was monitored without incident. The error was discovered after the infusions were completed, with staff noting that medication bags were clearly labeled but not properly verified before administration.
Two residents with significant skin integrity concerns did not receive timely assessment, documentation, or initiation of care plans and wound care orders as required by facility policy and professional standards. Delays in care plan initiation and documentation, as well as missed physician orders, resulted in inadequate management of pressure injuries and wounds.
Surveyors identified that the facility failed to properly document and communicate required information during acute transfers and discharges for two residents. In one case, NTACF forms lacked resident representative details and did not include bed-hold or reserve payment information. In another case, a discharge summary was missing the resident or representative's signature, lacked evidence of communication, and contained outdated vital signs, with no physician discharge order documented.
A resident with severe cognitive impairment and a feeding tube received 800 ml of enteral feeding over four hours instead of the physician-ordered 60 ml/hr due to an LPN's failure to properly set up and monitor the feeding pump. The tube feeding was administered by gravity rather than through the pump, and the error was not promptly identified. The resident developed respiratory distress, was hospitalized with aspiration pneumonia, and subsequently expired.
A nurse failed to wear the required PPE, specifically a gown, while providing tube feeding care to a resident on Enhanced Barrier Precautions, despite facility policy and clear signage. The resident had significant medical needs, including a feeding tube and impaired cognitive function. The CNA followed proper protocol, but the RN did not, resulting in noncompliance with infection prevention procedures.
Failure to Provide Adequate Fall Prevention and Supervision During Bathing
Penalty
Summary
A deficiency occurred when the facility failed to develop and follow adequate fall prevention interventions for a resident assessed as high risk for falls. The resident had multiple diagnoses, including heart failure, diabetes, muscle weakness, abnormal gait, and required substantial or maximal assistance with bathing. The care plan specified that the resident should be supervised at all times while in the shower and that a towel should be placed on the shower chair to prevent slipping. Despite these interventions, an incident occurred when a CNA left the resident alone on the shower chair to retrieve a towel from the resident's room. During this time, the resident slid off the shower chair and was found on the bathroom floor. Documentation and interviews confirmed that the CNA did not follow the care plan's directive for continuous supervision during bathing. Other staff interviews indicated that it was standard practice to bring all necessary items into the bathroom before starting care and not to leave residents unattended during showers. The Director of Nursing stated that the resident should have received assistance as outlined in the care plan, but also indicated it was acceptable for the CNA to leave the resident briefly. There was no explanation provided for the discrepancy between the level of assistance required as indicated in the resident's assessment and the care plan. Facility policies required comprehensive, person-centered care plans and investigation of incidents to evaluate care and prevent recurrence, but these were not adequately followed in this case.
Failure to Document ADL Care Provided to Multiple Residents
Penalty
Summary
Surveyors identified that the facility failed to provide documented evidence of care for four residents, as required by policy. The deficiency was observed through missing signatures in the Point of Care (POC) flowsheets, which are used by Certified Nursing Assistants (CNAs) to document activities of daily living (ADLs) such as personal hygiene and toileting hygiene. The missing documentation occurred across multiple dates and shifts for each resident, indicating a pattern of incomplete record-keeping. The residents involved had varying medical conditions, including dementia, diabetes, muscle weakness, anxiety, chronic obstructive pulmonary disease, acute kidney failure, Alzheimer's disease, and heart failure. Their cognitive statuses ranged from severely impaired to intact, and their required levels of assistance with ADLs varied from supervision to total dependence. Despite these needs, the POC flowsheets for each resident showed numerous instances where care was not documented as provided, with blank entries for both personal hygiene and toileting hygiene across different shifts and months. Interviews with facility staff, including a CNA, the LPN Unit Manager, and the DON, confirmed that CNAs were responsible for documenting care in the POC system and that supervisory staff were expected to ensure documentation was completed each shift. The facility's own policy required that all services provided to residents be documented in the medical record, including the date and time of care. The lack of documentation for multiple residents and shifts was therefore not in accordance with facility policy or regulatory requirements.
Failure to Assess and Implement Elopement Risk Interventions
Penalty
Summary
The facility failed to adequately assess and implement measures to protect a resident identified as high risk for elopement upon admission. The resident, who had diagnoses including cognitive communication deficit, type II diabetes, metabolic encephalopathy, acute kidney failure, and an anxiety disorder, was admitted with a history of restlessness, aggressiveness, and a prior elopement attempt. Despite these risk factors, the resident's care plan and progress notes did not include any focus or interventions related to elopement risk, and there was no completed elopement assessment in the medical record prior to the incident. On the night of the incident, a CNA discovered the resident missing from their room during rounds, with a window open and evidence suggesting the resident exited through it. The facility initiated a search and notified appropriate parties. Documentation revealed conflicting assessments regarding the resident's elopement risk, with one assessment indicating high risk and another indicating no risk. The staff involved, including the nursing supervisor and LPNs, provided inconsistent information about the completion and content of elopement risk assessments. Interviews with facility leadership confirmed that the expectation was for all new admissions to be assessed for elopement risk and for interventions to be implemented if risk was identified. The facility's own policy required a systemic approach to monitoring and managing residents at risk for elopement, including assessment and person-centered care planning. However, these procedures were not followed for this resident, resulting in the failure to provide adequate supervision and accident hazard prevention as required.
Facility Assessment Lacks Ventilator-Dependent Resident Planning
Penalty
Summary
The facility failed to ensure that its facility-wide assessment (FA) adequately identified and addressed the required services and procedures necessary for ventilator-dependent residents. Upon review, the FA did not specify that the facility was licensed for 12 ventilator care beds in addition to 220 long-term care beds, nor did it include ventilator-dependent residents under the sections for diseases/conditions, resident support/care needs, staff training/education and competencies, or physical environment and equipment needs. The FA only referenced general respiratory conditions such as COPD, pneumonia, asthma, and respiratory failure, but did not specifically mention ventilator dependency or related requirements. During interviews, facility leadership confirmed that the FA was current but could not identify any vent-specific or related assessments within the document. When asked, the Vice President of Clinical stated that ventilator care was covered under the general respiratory category, and the President of Operations asserted that federal regulations do not require specific mention of ventilator care in the FA. The surveyor noted that the omission of ventilator-specific planning, licensing, and resources in the FA constituted a deficiency, as the facility did not comprehensively address the needs of ventilator-dependent residents as required.
Unlicensed Staff Assigned to Retrieve and Transport Methadone
Penalty
Summary
The facility failed to develop and implement a procedure for the safe acquisition and receipt of physician-ordered Methadone, a controlled substance, from a third-party clinic. Instead, the facility assigned an unlicensed staff member, a Certified Nursing Assistant (CNA), to travel to the outside clinic to pick up Methadone for multiple residents. The CNA transported the Methadone in a locked box with the key in her possession, using her personal vehicle, and delivered it to the facility's nursing staff. Interviews with the CNA, the Director of Nursing (DON), and review of facility documents confirmed that this practice occurred over several weeks, and that there was no specific policy or procedure in place for this process. The facility's existing policy stated that controlled substances should be delivered and signed for by a licensed nurse, but this was not followed in the case of Methadone pickups from the clinic. Further interviews revealed that the consultant pharmacist did not consider the Methadone clinic under his jurisdiction, and the DON acknowledged the lack of a specific policy for Methadone retrieval, relying instead on a general narcotic policy. Nursing staff interviewed stated that CNAs should not handle or deliver narcotics or any type of medication, as they are not licensed to do so. The facility's corporate office also lacked a specific policy for this process. The deficiency was identified through observations, interviews, and document reviews conducted by surveyors, and was cited under relevant state regulations.
Significant Medication Error Due to Failure to Follow Medication Administration Protocols
Penalty
Summary
A significant medication error occurred when an LPN administered intravenous (IV) antibiotics to the wrong residents. Specifically, one resident with a physician's order for Meropenem for a heel wound infection received Zosyn, while another resident with an order for Zosyn for a toe infection received Meropenem. The error was discovered after the IV infusions were completed, with the medication bags clearly labeled with the respective residents' names and medications. The LPN reported issues with computer access and poor lighting at the time of administration, which contributed to the failure to follow the facility's medication administration procedures, including the required three checks and the 5 Rights of Medication Administration. The resident who received the incorrect medication (Zosyn instead of Meropenem) experienced adverse effects, including vomiting, flushed face, chills, and was subsequently transferred to the hospital, where they were admitted with a diagnosis of drug reaction, fever, and tachycardia. The other resident who received Meropenem instead of Zosyn was closely monitored and did not display any adverse effects. Both residents had complex medical histories, including osteomyelitis and other chronic conditions, and required assistance with activities of daily living. The error was immediately reported to the medical doctor, and the residents were monitored following the incident. The investigation revealed that the LPN did not adhere to established medication administration protocols, despite having completed competency checks and education on these procedures. The LPN prepared both residents' IV antibiotics at the nurse station desk due to computer issues and administered them without proper verification. The error was identified when the Clinical Manager responded to IV pump alarms and noticed the medications had been switched. Statements from staff confirmed that the LPN did not follow the required safety checks, leading to the administration of the wrong medications.
Removal Plan
- LPN #1 was found to administer the incorrect IV antibiotic medications to Resident #1 and Resident #2; MD was notified and both residents were closely monitored
- Nurse medication administration observation checklist was completed and LPN #1 demonstrated competency after medication error was found
- LPN #1 was suspended and terminated
- A 100% audit of all current residents that have physician order of IV antibiotics were reviewed by the assistant director of nursing (ADON) to validate the correct IV antibiotics orders and that IV medications were in the medication room
- Medication administration education began and IV competencies began for all nurses - all nursing staff must complete education and competencies before their next scheduled shift
- All newly hired nurses will be educated on proper medication administration including return demonstration during orientation
- A new process was created requiring two nurses to verify the correct IV medication before administering to residents
- Random audits were being conducted monitoring nurses who were administering IVs
Failure to Timely Assess and Intervene for Skin Integrity Issues
Penalty
Summary
The facility failed to ensure that residents received timely assessment, monitoring, and implementation of appropriate interventions for skin integrity concerns, resulting in deficiencies for two residents. For one resident admitted with multiple stage 2 pressure injuries and bruising, documentation showed that although wounds were identified upon admission, there was a lack of timely care plan initiation and physician orders for wound care. The care plan and treatment orders were not established until several days after admission, despite the presence of significant skin issues. The Director of Nursing confirmed that there was no care plan in place upon the resident's return from the hospital and that wound care orders were not entered as required. Another resident was admitted with a history of cerebral infarction and diabetes mellitus and was found to have an open area with redness and swelling on the left thigh. Although an incident report was completed and the nurse practitioner was notified, there was a delay in documenting the skin assessment and initiating a care plan. The care plan for the wound was not started until after the resident returned from the hospital, well beyond the required timeframe. Progress notes indicated that the wound worsened, leading to a hospital transfer for surgical evaluation. The Director of Nursing acknowledged that the care plan should have been initiated within 24 hours but was not. Facility policies require a full body skin assessment on admission, timely documentation, prompt initiation of care plans, and immediate notification of providers and families for new skin impairments. However, in both cases, there were lapses in following these protocols, including delays in documentation, care plan initiation, and implementation of physician orders for wound care. These failures resulted in residents not receiving the necessary care and services to maintain their highest practicable physical well-being, as required by professional standards and facility policy.
Deficient Documentation and Notification During Transfers and Discharges
Penalty
Summary
The facility failed to ensure proper documentation and notification regarding acute transfers and discharge procedures for two residents. For one resident who experienced unplanned transfers to an acute hospital, the Notice of Transfer to Acute Care Facility (NTACF) forms did not include required information about the resident representative (RR), such as contact details and confirmation of notification. Additionally, there was no documentation that the RR was informed about the facility's bed-hold policy or reserve payment, as required by both facility policy and state regulations. The Director of Nursing (DON) and Director of Admissions (DA) confirmed that these omissions occurred, and the forms were not fully completed, including missing the billing rate information. For another resident who was discharged, the discharge summary lacked the signature of the resident or RR, and there was no evidence that the discharge summary or instructions were communicated to them. The discharge summary also contained outdated vital signs, with the last recorded measurements taken several hours before the actual discharge time. Furthermore, there was no documented physician order for the discharge, and the facility's policy requiring assessment and documentation of the resident's condition at discharge was not followed. These deficiencies were identified through interviews and record reviews conducted by surveyors, who found that the facility did not adhere to its own policies or regulatory requirements regarding notification, documentation, and communication with residents and their representatives during transfers and discharges.
Improper Tube Feeding Administration Resulting in Resident Harm
Penalty
Summary
A deficiency occurred when a severely cognitively impaired resident, who was dependent on staff for all activities of daily living and had a feeding tube due to NPO status and dysphagia, received improper administration of tube feeding. The physician's order specified that the resident was to receive enteral feeding at a rate of 60 ml per hour, but instead, the resident received 800 ml of tube feeding over four hours. This was due to the failure of an LPN to properly set up and monitor the feeding pump, resulting in the tube feeding being administered by gravity rather than through the pump at the prescribed rate. The facility's policy required that all tube feedings be administered by a registered nurse or LPN in accordance with specific procedures, including verifying the physician's order, ensuring the tube is secure, setting the pump to the correct rate, and monitoring the pump's function. However, the LPN did not thread the feeding tube through the pump and did not monitor the feeding pump to ensure it was functioning properly. As a result, the resident received a large volume of feeding in a short period, which was not in accordance with the physician's order. Staff interviews and documentation revealed that the error was not promptly identified. The resident was found with symptoms of respiratory distress and a critically low oxygen saturation level. The resident was subsequently sent to the hospital, where they were diagnosed with aspiration pneumonia and later expired. The facility's failure to follow its tube feeding policy and to monitor the resident appropriately led to this outcome.
Failure to Follow Enhanced Barrier Precautions During Tube Feeding Care
Penalty
Summary
A deficiency was identified when a Registered Nurse (RN) failed to wear the required Personal Protective Equipment (PPE), specifically a gown, while providing care to a resident on Enhanced Barrier Precautions (EBP). The RN entered the resident's room to flush and disconnect a feeding tube without donning a gown, despite facility policy and CDC guidance requiring gown and gloves for high-contact care activities such as tube feeding. The Certified Nursing Assistant (CNA) was observed entering the same room with the appropriate PPE, and both staff members confirmed the resident was on EBP due to the presence of a feeding tube. The resident involved had a history of cerebral infarction, aphasia, and dysphagia, and was assessed as having severely impaired cognitive skills. Facility documentation, including the resident's Plan of Care and the policy on Enhanced Barrier Precautions, specified the need for PPE during high-contact care. The RN acknowledged not following the protocol, while the CNA demonstrated compliance. The facility's policy outlined the importance of PPE use to prevent the spread of multidrug-resistant organisms, but this protocol was not consistently followed during the observed care.
Some of the Latest Corrective Actions taken by Facilities in New Jersey
- Initiated comprehensive medication-administration and IV-competency training for all nurses before their next shift (J - F0760 - NJ)
- Established mandatory orientation education with return demonstration on proper medication administration for all newly hired nurses (J - F0760 - NJ)
- Established a two-nurse verification process for IV medications before administration (J - F0760 - NJ)
- Implemented ongoing random audits of nurses administering IVs (J - F0760 - NJ)
Significant Medication Error Due to Failure to Follow Medication Administration Protocols
Penalty
Summary
A significant medication error occurred when an LPN administered intravenous (IV) antibiotics to the wrong residents. Specifically, one resident with a physician's order for Meropenem for a heel wound infection received Zosyn, while another resident with an order for Zosyn for a toe infection received Meropenem. The error was discovered after the IV infusions were completed, with the medication bags clearly labeled with the respective residents' names and medications. The LPN reported issues with computer access and poor lighting at the time of administration, which contributed to the failure to follow the facility's medication administration procedures, including the required three checks and the 5 Rights of Medication Administration. The resident who received the incorrect medication (Zosyn instead of Meropenem) experienced adverse effects, including vomiting, flushed face, chills, and was subsequently transferred to the hospital, where they were admitted with a diagnosis of drug reaction, fever, and tachycardia. The other resident who received Meropenem instead of Zosyn was closely monitored and did not display any adverse effects. Both residents had complex medical histories, including osteomyelitis and other chronic conditions, and required assistance with activities of daily living. The error was immediately reported to the medical doctor, and the residents were monitored following the incident. The investigation revealed that the LPN did not adhere to established medication administration protocols, despite having completed competency checks and education on these procedures. The LPN prepared both residents' IV antibiotics at the nurse station desk due to computer issues and administered them without proper verification. The error was identified when the Clinical Manager responded to IV pump alarms and noticed the medications had been switched. Statements from staff confirmed that the LPN did not follow the required safety checks, leading to the administration of the wrong medications.
Removal Plan
- LPN #1 was found to administer the incorrect IV antibiotic medications to Resident #1 and Resident #2; MD was notified and both residents were closely monitored
- Nurse medication administration observation checklist was completed and LPN #1 demonstrated competency after medication error was found
- LPN #1 was suspended and terminated
- A 100% audit of all current residents that have physician order of IV antibiotics were reviewed by the assistant director of nursing (ADON) to validate the correct IV antibiotics orders and that IV medications were in the medication room
- Medication administration education began and IV competencies began for all nurses - all nursing staff must complete education and competencies before their next scheduled shift
- All newly hired nurses will be educated on proper medication administration including return demonstration during orientation
- A new process was created requiring two nurses to verify the correct IV medication before administering to residents
- Random audits were being conducted monitoring nurses who were administering IVs
Failure to Supervise Cognitively Impaired Resident Results in Heat Stroke
Penalty
Summary
A cognitively impaired resident with multiple complex medical conditions, including dementia, multiple sclerosis, encephalopathy, and a history of falls and strokes, was found unresponsive on an outdoor patio during a period of extreme heat. The resident had a severely impaired cognition, as indicated by a Brief Interview for Mental Status (BIMS) score of 3 out of 15, and required staff assistance for activities of daily living and mobility. Facility records and staff interviews confirmed that the resident could not ambulate independently and required one-person assistance for ambulation. On the day of the incident, the resident was last seen in the dayroom by assigned staff, but was later discovered outside on the patio by a companion, unresponsive and exposed to direct sunlight. The companion immediately alerted a nurse, who found the resident unconscious with a temperature of 103.8°F and a heart rate of 124 bpm. The resident was brought inside, treated for heat stroke, and subsequently transferred to the emergency room for further evaluation and care. Interviews with staff revealed inconsistencies regarding supervision in the dayroom and the process by which the resident accessed the patio, with staff unable to account for the resident's movement outside or provide clear oversight during the critical period. Facility policies required supervision of cognitively impaired residents and specific precautions during periods of extreme heat, including staff monitoring and prevention of heat-related illness. However, documentation and interviews indicated lapses in supervision and failure to ensure the resident's safety, as no staff observed or prevented the resident from being outside unsupervised during hazardous weather conditions. The lack of effective oversight and adherence to established protocols resulted in the resident suffering a life-threatening heat stroke, constituting neglect.
Removal Plan
- Resident was assessed and transferred to emergency room for evaluation.
- Resident returned to the facility and was placed on monitoring.
- The nurse and CNA who were assigned to Resident were in-serviced on resident safety and protection from neglect.
- Resident was placed on one-to-one supervision.
- All cognitively impaired residents were placed on monitoring.
- The LNHA, DON, and ADON reviewed the abuse and neglect policy, taking residents outside the facility, hot weather, enhanced supervision, and nursing round policies with no revisions made.
- The DON, ADON, LNHA provided the nurses and CNAs with training on the abuse and neglect policy, resident supervision, protection of resident from neglect, and resident safety.
- The DON, ADON, and LNHA provided non-clinical staff training on abuse and neglect and residents' rights to be free from neglect.
Elopement Due to Inadequate Supervision and Identification Failures
Penalty
Summary
A cognitively impaired resident with a history of exit-seeking behaviors was able to elope from a secured unit due to inadequate supervision and failure to follow established identification protocols. The resident, who had diagnoses including dementia, depression, anxiety disorder, and altered mental status, was assessed as needing supervision for decision-making regarding wandering and elopement risk. Despite documented behaviors such as repeatedly asking to go home and inquiring about how to leave the facility, staff did not consistently reassess or update interventions after these behaviors were observed and reported. On the day of the incident, the resident was able to exit the secured unit after an LPN, unfamiliar with the resident and not given a report, asked a CNA to use her badge to open the locked door, mistakenly believing the resident was a visitor. Both staff members failed to check the posted pictures of residents at risk for elopement, which were intended to help staff identify and prevent such incidents. The resident, wearing an ID band, proceeded to the first-floor lobby and exited the building through the front door while carrying bags of clothing. The security guard at the front desk also failed to recognize the resident as a patient and did not intervene, only responding after being alerted by a visitor. Interviews and documentation revealed that staff on the unit, including the LPN and CNA involved, did not recognize the resident or utilize the available identification tools, such as the posted photographs and ID bands. Communication lapses were evident, as the LPN was not educated about the identification system and had not received a report on the resident. The facility's policy required staff to identify and intervene with residents at risk for elopement, but these procedures were not followed, resulting in the resident leaving the building unsupervised.
Removal Plan
- Resident was assessed post incident by Nursing Supervisor, placed on 1:1 monitoring for safety.
- A call was placed to the primary physician by the nursing supervisor.
- The nursing supervisor updated Resident's care plan.
- All staff were re-educated on the Elopement Policy.
- A new system was implemented that all visitors must sign out upon leaving the building.
- Security staff and receptionist staff were educated on the Elopement Policy and the new process for visitors signing out.
- All nursing staff were re-educated on identifying elopement behaviors and initiating and completing a new Elopement Assessment, updating the resident's care plan and placing the resident picture at the entrance of the unit, receptionist desk, and security console.
- An audit was completed on all residents who are an elopement risk to ensure they have an appropriate Care Plan, Elopement Assessment and resident picture at receptionist binder and security console.
- An audit was completed on all new admissions by the Infection Preventionist nurse and Nursing Supervisor to assure that residents identified at risk of elopement had an elopement care plan in place, ID band and picture on the wall of exit door and front reception desk and security desk.
- An audit was completed by the Nursing Supervisor on resident ID bands to ensure all residents had an ID band in place and that all resident pictures were present in Point Click Care as a form of identification. Refusal of pictures and/or ID band were indicated on the resident's care plan.
- The DON, ADON and ICP re-reviewed the Elopement Policy.
- The Nursing Supervisor and the ADONs completed the re-education on the Elopement Policy for staff.
- All unit doors continue to remain locked and continue to require a swipe ID card to get off all the Nursing Units.
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