Based on observation, interviews, review of medical records, and review of other pertinent facility documents on 07/23/2026, it was determined that the facility failed to maintain a safe environment for a resident (Resident #2), with severe cognitive impairment. The facility staff failed to follow their Resident Leaves of Absence policy requiring authorization by Resident #2's Power of Attorney (POA), before the resident left the facility with a caregiver. This deficient practice was identified for 1 of 3 residents (Resident #2) reviewed for incidents and was evidenced by the following: On 7/19/2026 at approximately 9:30 AM, an outside Home Health Aide (HHA #1) informed facility staff that they were at the facility to take Resident #2 out on a Leave of Absence (LOA) pass. …
F689 citations in New Jersey
Accidents and supervision · Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
New Jersey cites F689 less often than its own record predicts
0.60 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 F689.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What New Jersey surveyors wrote
F689 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 #3007960Based on interviews, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure a resident (Resident #144), who was dependent on staff for transfers, was safely and properly transferred with two staff members via a mechanical lift. On 5/4/26, the resident was transferred by one staff member from their bed to a shower chair, which resulted in the resident sustaining a left upper extremity humeral fracture (a fracture of the left upper arm). …
Based on observations, interviews, record review, and review of other pertinent facility provided documentation, the facility failed to ensure each resident who was at risk for elopement was appropriately supervised and monitored to ensure safety, prevent elopement, and/or exiting of the building. Specifically, the facility failed to: a.) ensure the order and care plan included a function check of the wander guard for 1 of 3 residents (Resident #55), b.) test the battery status of the wander guards weekly as per the recommendation of the manufacturer for 3 of 3 residents (Resident #2, Resident #55, and Resident #97), and c.) have a policy/procedure in place for the wander guard bracelet or system used by the facility for 3 of 3 residents (Resident #2, Resident #55, and Resident #97). …
The short window
Recent years
| Year | Share of New Jersey citations | vs expected |
|---|---|---|
| 2023 | 3.19% | 0.65× |
| 2024 | 2.57% | 0.48× |
| 2025 | 3.35% | 0.60× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else New Jersey surveyors cite →
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