Complaint #3041277 Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) develop and implement an effective water management plan in accordance with nationally accepted standards to mitigate the growth of Legionella bacteria in the facility's water system, b.) follow the recommended guidance from the New Jersey Department of Health's (NJDOH) Communicable Disease Service (CDS) including biweekly water testing and conducting a root cause analysis to identify and address any hazardous conditions, and c.) implement corrective actions for nine occupied resident rooms that tested positive for Legionella. This deficient practice had the potential to affect all 53 residents. …
F880 citations in New Jersey
Infection prevention and control · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
New Jersey cites F880 more often than its own record predicts
1.04 times the share F880 takes of citations nationally.
Of every deficiency written in New Jersey in 2025, this is the portion that was F880.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What New Jersey surveyors wrote
F880 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 #: 2981080, 3071351 Based on observation, interview, and review of pertinent facility documents on 08/20/2026 and 08/21/2026, it was determined that the facility failed to follow appropriate hand hygiene during administration of medication to a cognitively impaired resident (Resident #2) during observation of medication administration for 1 of 8 residents (Resident #2). This deficient practice was evidenced by the following:Reference:The CDC Clinical Safety: Hand Hygiene for Healthcare Workers dated 02/27/24 revealed that handwashing with water and soap (plain soap or with an antiseptic), use of an antiseptic hand rub (alcohol-based foam or gel hand sanitizer), or surgical hand antisepsis in situations including but not limited to: immediately before touching a patient; before… …
Based on observation, interview, and review of other pertinent facility documents, it was determined that the facility failed to follow appropriate infection control practices for educating housekeeping staff for Environmental Protection Agency approved disinfecting products contact times during a COVID-19 Focused Survey. This deficient practice was identified for 4 of 4 housekeeping staff, and was evidenced by the following: On 6/5/2020 at 09:30 AM, the surveyor conducted an entrance conference with the facility's Administrator and Director of Nursing (DON). The DON indicated that the facility had 30 residents that were COVID-19 positive (C19+), ten C19+ residents in the hospital and currently there were no staff out due to C19+. …
The short window
Recent years
| Year | Share of New Jersey citations | vs expected |
|---|---|---|
| 2023 | 6.32% | 1.23× |
| 2024 | 5.99% | 1.06× |
| 2025 | 6.42% | 1.04× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else New Jersey surveyors cite →
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