TRENTON, NJ - Federal health inspectors issued immediate jeopardy citations to Providence Nursing and Rehabilitation Center following a June 2024 inspection that revealed multiple critical failures in basic resident care and safety protocols.
Residents Found in Soiled Bedding
During an early morning inspection tour on June 18, 2024, federal surveyors documented disturbing conditions affecting multiple residents at the facility. On the second floor, inspectors found a resident lying on a fitted sheet with large brown and yellow stains that smelled of urine, along with dried fecal matter. The protective pad placed over the sheet was dry, indicating the soiled linens had been left unchanged from a previous shift.
When questioned, the unit manager acknowledged that the certified nursing aide responsible for the resident's care should have changed the contaminated sheet during routine incontinence care. The manager attributed the lapse to an agency nursing aide who had worked the overnight shift.
Less than an hour later on the first floor, inspectors discovered another resident lying in a very wet incontinence brief with sheets saturated in urine producing a strong odor. The non-verbal resident had been left in these conditions despite facility protocols requiring incontinence checks every two hours.
Extended exposure to moisture and waste products creates significant health risks for nursing home residents. Prolonged contact with urine and feces breaks down the skin's protective barrier, creating an environment where harmful bacteria can proliferate. This bacterial exposure increases the risk of urinary tract infections, which can progress to serious bloodstream infections in vulnerable elderly populations. The ammonia in urine can cause chemical burns to sensitive skin, while the combination of moisture and friction leads to painful skin breakdown.
Inadequate Staffing Levels Documented
The inspection revealed systematic staffing shortages contributing to care failures. On June 18, the first floor operated with just five certified nursing aides responsible for 50 residents, with one aide assigned to care for 11 residents. The second floor had five aides covering 47 residents, including one aide responsible for 13 residents.
During interviews, the facility's staffing coordinator acknowledged the nursing home "did not always meet the required ratios" mandated by state regulations. New Jersey regulations require one aide for every eight residents during morning shifts, one aide per ten residents on evening shifts, and one aide per 14 residents overnight.
The staffing coordinator stated the facility found it "very hard to find staff" and relied heavily on agency personnel to fill gaps. This heavy dependence on temporary agency staff creates continuity of care issues, as agency workers may be unfamiliar with individual residents' needs and facility protocols.
Medication Safety Protocols Violated
Federal surveyors observed significant medication administration safety violations on June 18. A registered nurse was documented using another staff member's electronic login credentials to sign medication records, a practice that compromises the entire medication tracking system.
The nurse explained she borrowed a unit manager's password because she experienced problems with her own login credentials. Inspectors observed the nurse entering electronic signatures for medications she had already administered earlier that morning to ten different residents, including both sampled and non-sampled residents in the inspection.
The practice of using another person's login credentials eliminates accountability in medication administration. Electronic medication records serve as legal documentation of which medications were given to which residents, by whom, and at what time. When nurses share passwords, it becomes impossible to verify who actually administered medications, creating potential liability issues and making it difficult to trace errors back to their source.
The unit manager who provided her password confirmed that medications should be signed immediately after administration to the resident, not retroactively in batches. Delayed documentation increases the risk that medications could be administered twice or skipped entirely, as real-time records are not available to other staff members.
Infection Control Program Lacking Leadership
The facility operated without a designated infection preventionist for two to three months prior to the inspection. During the entrance conference on June 17, administrators acknowledged this vacancy and explained that the assistant director of nursing, two unit managers, and the director of nursing had divided infection control responsibilities among themselves.
When inspectors requested infection control certifications, they discovered that only one unit manager held such certification. The director of nursing confirmed she had no infection control certification, nor did the assistant director of nursing who was responsible for training staff on infection control practices.
Professional infection control requires specialized knowledge of epidemiology, microbiology, and disease transmission patterns. Certified infection preventionists receive training in surveillance methods, outbreak investigation, antibiotic stewardship, and regulatory compliance. Without this expertise, facilities may fail to recognize emerging infection patterns or implement appropriate containment measures.
The assistant director of nursing confirmed she completed the May 2024 antibiotic stewardship review on June 19 - the day before inspectors interviewed her about the process. This delay in reviewing antibiotic use undermines the purpose of stewardship programs, which aim to ensure appropriate prescribing and reduce antibiotic resistance.
Pharmacy Recommendations Ignored for Months
Inspectors discovered that consultant pharmacist recommendations from March, April, and May 2024 remained unaddressed until June 19, 2024 - only after surveyors requested the documentation. The facility's consultant pharmacist, who began serving the facility in March 2024, emphasized the importance of acting on pharmacy recommendations as soon as possible to address medication safety concerns immediately.
Monthly pharmacy reviews serve as a critical safety check, identifying potential drug interactions, inappropriate dosing, duplicate therapies, and opportunities to discontinue unnecessary medications. Delays of three months in implementing these recommendations expose residents to preventable medication-related problems.
The director of nursing stated that an appropriate timeframe for completing consultant pharmacist recommendations was within seven days of receiving them, but could not explain the three-month delay. A unit manager revealed that recommendations were not distributed to nursing staff for action until the day before inspectors inquired about them.
Investigation Failures Documented
Inspectors reviewed a closed case involving a resident who sustained serious injuries while on one-to-one monitoring in August 2023. The incident report documented that staff found the resident with blue discoloration on both ears, a three-centimeter abrasion on the right knee, discoloration on the right side of the face and mid-arm, and screaming in pain when staff attempted repositioning.
Emergency room evaluation revealed the resident had sustained a lower back fracture. The incident was classified as an unwitnessed fall, despite the resident being on continuous one-to-one monitoring every shift - meaning a staff member should have been directly observing the resident at all times.
The facility's investigation failed to address the fundamental question of how a resident under constant observation sustained multiple injuries including a spinal fracture through an unwitnessed event. The administrator acknowledged during the exit conference that the investigation should have included assessment of how a resident on one-to-one monitoring experienced an unwitnessed fall.
Facility Assessment Incomplete
Federal regulations require nursing homes to conduct comprehensive facility-wide assessments identifying the resources necessary to care for their specific resident population. Inspectors discovered that Providence Nursing's facility assessment, last updated in September 2023 and reviewed in April 2024, failed to identify registered sex offenders and incarcerated residents from the county jail as part of the facility's special populations.
During the initial tour, inspectors observed residents who were incarcerated, with four corrections officers present in one room. The administrator confirmed on June 24 that the facility housed both registered sex offenders and inmates from the local county jail, yet these populations were not reflected in the facility assessment signed by the administrator just two months earlier.
Caring for incarcerated residents and registered sex offenders requires additional security measures, specialized training for staff, and protocols to protect both these residents and others in the facility. The failure to identify these populations in the facility assessment indicates inadequate planning for the resources and procedures necessary to serve them safely.
Systemic Quality Improvement Failures
The inspection revealed that multiple deficiencies cited during the facility's previous standard survey in October 2022 had recurred, including problems with assessment accuracy, medication storage, consultant pharmacist report follow-up, antibiotic stewardship, and the facility assessment itself.
During the exit conference, administrators acknowledged they used previous survey deficiencies to guide their quality improvement program. However, the recurrence of the same violations demonstrates that corrective actions implemented after the 2022 survey failed to create sustainable improvements in care delivery.
The administrator, who started at the facility in April 2024, confirmed she had reviewed the previous survey findings and participated in quarterly quality improvement meetings. The director of nursing stated the facility had educated staff and completed reports, but could not explain why the same problems persisted.
Regulatory Context
The immediate jeopardy determination represents the most serious category of nursing home deficiencies, indicating that the facility's practices have caused or are likely to cause serious injury, harm, impairment, or death to residents. Facilities receiving immediate jeopardy citations must implement corrective actions immediately to remove the threat to resident safety.
The Centers for Medicare and Medicaid Services can impose significant penalties for immediate jeopardy violations, including denial of payment for new admissions, civil monetary penalties, temporary management, and termination from the Medicare and Medicaid programs.
Providence Nursing and Rehabilitation Center is located at 439 Bellevue Avenue in Trenton, New Jersey. The facility is required to submit a plan of correction detailing how it will address each deficiency and prevent recurrence.
For complete inspection details and the facility's plan of correction, consult the official survey report available through the New Jersey Department of Health or the Centers for Medicare and Medicaid Services nursing home compare website.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Providence Nursing and Rehabilitation Center from 2024-06-26 including all violations, facility responses, and corrective action plans.
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