Complaint #NJ182121 Based on interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to report within two hours to the New Jersey Department of Health (NJDOH) an allegation of staff-to-resident physical abuse for a cognitively intact resident (Resident #381) who reported being roughly handled by a Certified Nursing Assistant (CNA #1). This deficient practice was identified for 1 of 1 residents reviewed for abuse (Resident #381). A review of the Progress Note (PN) dated 12/28/24 at 9:16 AM, revealed that Resident #381, a cognitively intact resident, reported to the Registered Nurse (RN #1) that they were fearful of staff and the facility due to an incident that had occurred two days prior (12/26/24). …
F609 citations in New Jersey
Reporting alleged violations · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
New Jersey cites F609 less often than its own record predicts
0.86 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 F609.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What New Jersey surveyors wrote
F609 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.
Based on interviews and record review of pertinent facility documentations on 7/23/26 and 7/24/26, it was determined that the facility failed to report to the New Jersey Department of Health (NJDOH) an allegation of attempted sexual assault of a resident (Resident #1), in accordance with the required timeframe for abuse reporting. The facility staff was made aware about the abuse allegation on July 19, 2026, at 9:00 AM, and they did not report the incident to NJDOH till after the surveyor inquiry during the survey on 7/23/26 and 7/24/26. …
COMPLAINT # NJ 3 Based on interviews, Medical Record (MR) review and review of pertinent facility documents on 7/30/19, it was determined that the facility failed to notify proper law enforcement agencies as well as failure to follow the facility's policy titled Abuse Prevention-Mandatory Reporting for 2 of 2 sampled for abuse (Resident #2 and #3). This deficient practice was evidenced by the following: 1. According to the Admission Record (AR), Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. According to the Minimum Data Set (MDS), an assessment tool dated 4/16/19, Resident #2 had a Brief Interview for Mental Status (BIMS) score of 0/15, indicating Resident #2 had severe cognitive impairment. …
The short window
Recent years
| Year | Share of New Jersey citations | vs expected |
|---|---|---|
| 2023 | 2.45% | 1.24× |
| 2024 | 2.67% | 1.17× |
| 2025 | 2.11% | 0.86× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else New Jersey surveyors cite →
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