Incident 2684633Based on interviews, review of the medical records, and review of other pertinent facility documentation, it was determined that the facility failed to properly administer tube feeding as ordered, and to monitor a severely cognitively impaired resident (Resident #2) on tube feeding; which caused the resident to receive 800 milliliters (ml) of tube feeding in 4 hours instead of the physician ordered 60ml per hour (which should be 240 ml in 4 hours). Nursing staff found Resident #2 with symptoms of respiratory distress on [DATE] at approximately 10:30 PM., and their oxygen saturation (the amount of oxygen circulating in the blood) reading at 63% (healthy levels 95 - 100%) on room air. At that time, the facility called 911 emergency to transport Resident #2 to the hospital. …
F693 citations in New Jersey
Tube feeding · Quality of Life and Care Deficiencies
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
New Jersey cites F693 less often than its own record predicts
0.72 times the national share — cited less often here than elsewhere.
Of every deficiency written in New Jersey in 2025, this is the portion that was F693.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What New Jersey surveyors wrote
F693 findings written in New Jersey, one from each severity band recorded here, most serious first.
Severity is as the surveyor wrote it. Some findings had already been corrected before the survey.
Complaint Intake #NJ 8 Based on interviews, record reviews, and facility policy reviews, it was determined that the facility failed to prevent complications from enteral (tube) feedings for one (Resident #1) of three residents reviewed for tube feedings. This deficient practice resulted in Resident #1 being found cyanotic (blue), and being admitted to the hospital and diagnosed with aspiration pneumonia (tube feeding in airway and lungs) due to lying flat in bed while the tube feeding was infusing. Resident #1 was then found in respiratory distress and was admitted to the hospital with aspiration pneumonia a couple of months later. Findings included: 1. …
Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure the appropriate management of gastrostomy enteral feeding formula. This deficient practice was identified for 1 of 3 residents (Resident #11) reviewed for tube feeding and was evidenced by the following:On 7/6/26 at 11:50 AM, the surveyor observed Resident #11 in bed with a gastrostomy enteral feeding tube (FT; a tube surgically inserted into the stomach to provide food and nutrients) pump administering an unidentified formula at a rate of 70 milliliters (mL) per hour. …
The short window
Recent years
| Year | Share of New Jersey citations | vs expected |
|---|---|---|
| 2023 | 0.49% | 0.65× |
| 2024 | 0.55% | 0.79× |
| 2025 | 0.50% | 0.72× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else New Jersey surveyors cite →
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