Based on observation, interviews, medical record review, and review of other pertinent facility documents, it was determined that the facility failed to A.) administer physician prescribed insulin to diabetic residents as ordered for 8 of 24 residents (Residents #22, #24, #33, #73, #74, #81, #260, and #261) residing on 2 of 2 floors and B.) failed to follow a physician order for weekly weights on 1 of 3 residents reviewed for nutrition, (Resident # 35). Failure to administer the prescribed insulin and/or blood sugars (BS) put diabetic residents at risk for hyperglycemic reactions (high blood sugar that affects people with diabetes. Skipping doses or not taking enough insulin to lower blood sugar can lead to hyperglycemia, hospitalization , and possible death). …
F658 citations in New Jersey
Professional standards of care · Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
New Jersey cites F658 more often than its own record predicts
2.26 times the share F658 takes of citations nationally.
Of every deficiency written in New Jersey in 2025, this is the portion that was F658.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What New Jersey surveyors wrote
F658 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 observation, interview, record review and review of pertinent facility documents, it was determined that the facility failed to follow their Abuse, Neglect and Exploitation Policy and Procedure, to protect residents from physical abuse and staff by failing to ensure: a.) Resident #37 was spoken to in a harsh and abusive manner which resulted in Resident #37 crying on 07/15/24, in the presence of the surveyor and b.) Resident #50 was protected from physical abuse by Resident #74, who had a history of wandering. On 01/24/2024, Resident #74 wandered into Resident #50's room and Resident # 74 physically assaulted Resident #50 by punching them in the mouth and knocking out their front tooth. …
Complaint #: 3026770Based on interview, medical record review, and review of other pertinent facility documentation on 08/27/26, it was determined that the facility failed to document on the Treatment Administration Record (TAR) according to the acceptable standards of nursing practice for 1 of 3 residents (Resident #5) reviewed for wound care documentation.This deficient practice was evidenced by the following:Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. …
The short window
Recent years
| Year | Share of New Jersey citations | vs expected |
|---|---|---|
| 2023 | 5.40% | 3.38× |
| 2024 | 5.33% | 3.25× |
| 2025 | 4.03% | 2.26× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else New Jersey surveyors cite →
Deficiency Index is independent and is not affiliated with, endorsed by, or approved by CMS, Medicare, or any government agency. About this data · Report a correction