Complaint #: NJ178530 Based on interviews, medical record review, and review of other pertinent facility documentation on 10/22/2024, 10/23/2024, 10/24/2024, and 10/29/2024, it was determined that the facility failed to a.) implement care plan (CP) interventions for a resident (Resident #1) with a known history of physically aggressive behaviors towards others and diagnoses of Traumatic Brain Injury (a head injury causing damage to the brain), Impulse Disorder (an inability to control impulses and behaviors), and Schizoaffective Disorder (a chronic mental health condition that combines symptoms of psychosis with symptoms of mood disorders). …
F656 citations in New Jersey
Comprehensive care plan · Resident Assessment and Care Planning Deficiencies
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
New Jersey cites F656 less often than its own record predicts
0.93 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 F656.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What New Jersey surveyors wrote
F656 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: 2600629, 2601350Based on interviews, review of medical records, and review of other pertinent facility documentation on 8/29/2025 and 9/02/2025, it was determined that the facility failed to a.) implement a resident's (Resident #1) comprehensive care plan for out on pass with escort only which resulted in the resident eloping and b.) develop a care plan for a resident post elopement. On 8/22/2025, Resident #1 was sitting outside the facility unescorted and was found wandering on a multi-lane highway by a passerby who brought the resident to the police precinct and had a syncopal episode (loss of consciousness) and was transferred to the emergency room.This deficient practice was identified for 1 of 3 sampled residents (Resident #1) and was evidenced by the following: According… …
COMPLAINT #3064225 Based on observation, interviews, review of medical records and other pertinent facility documentation on 8/3/26 and 8/4/26, it was determined that the facility failed to implement an established care plan intervention for Resident #5 when the resident, who the facility identified as requiring one-on-one supervision for safety reasons, was observed in their room without a staff member. This deficient practice was identified for 1 of 2 residents reviewed (Resident #5) for one-on-one supervision and was evidenced by the following:A review of Resident #5's admission Record revealed that the resident was admitted to the facility with diagnoses that included but were not limited to: psychosis (symptoms that happen when a person is disconnected from reality), schizophrenia (a… …
The short window
Recent years
| Year | Share of New Jersey citations | vs expected |
|---|---|---|
| 2023 | 3.13% | 0.87× |
| 2024 | 2.97% | 0.87× |
| 2025 | 3.21% | 0.93× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else New Jersey surveyors cite →
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