Complaint #: NJ185458 Based on interviews, medical record reviews, and review of other pertinent facility documentation on 5/8/25, it was determined that the facility failed to a.) update the care plan (CP) with interventions for a resident (Resident #6) who had multiple drug overdose incidents while at the facility and b.) follow the facility's policy titled Policy on Resident Care Planning. On 2/21/25 at approximately 6:30 PM, the Infection Preventionist (IP) observed Resident #6 slumped in his/her wheelchair. Resident #6's fingertips, lips, and lower half of face were cyanotic (blue), and he/she had loud breathing. The IP stated she administered Narcan to the resident. Approximately three minutes later, the resident responded to the Narcan and was sent to the hospital. …
F657 citations in New Jersey
Care plan timing and revision · Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
New Jersey cites F657 more often than its own record predicts
1.05 times the share F657 takes of citations nationally.
Of every deficiency written in New Jersey in 2025, this is the portion that was F657.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What New Jersey surveyors wrote
F657 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#: NJ00171849 Based on observations, interviews, medical record reviews, and review of other pertinent facility documentation on 4/15/24 and 4/16/24, it was determined that the facility failed to implement and revise care plan (CP) interventions for a resident who was experiencing pain resulted to a decline in condition, and failed to follow the facility policy for Pain and Comprehensive Care Plan for 1 of 3 residents (Resident #1) reviewed for implementation and revision of CP. This deficient practice was evidenced by the following: According to the admission record, Resident #1 was admitted with diagnoses that included but not limited to: Fall, Difficulty in Walking, and Adult Failure to Thrive. …
Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to revise an individual comprehensive care plan for a resident with an order for anticoagulants. This deficient practice was identified for 1 of 4 residents reviewed for accidents (Resident #71), and was evidenced by the following:On 7/20/26 at 7:05 AM, during initial tour of the facility, the surveyor observed Resident #71 lying in bed with their gown above their head. The surveyor observed the resident's bed in low position with fall mats to the right side of the bed. 07/21/2026 at 1:22 PM, the surveyor observed the resident in their room seated in a reclining chair. The resident was dressed appropriately and no concerns noted. …
The short window
Recent years
| Year | Share of New Jersey citations | vs expected |
|---|---|---|
| 2023 | 1.72% | 0.80× |
| 2024 | 2.01% | 1.05× |
| 2025 | 1.97% | 1.05× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else New Jersey surveyors cite →
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