Refer F 835 Based on interviews and a review of pertinent facility documents, it was determined that the facility failed to ensure that a.) a non-certified Nursing Aide (NA#1) received the required training and competencies needed prior to receiving their own assignment and rendering resident care which included but not limited to; bathing, toileting, transferring, feeding, personal hygiene, and grooming and b.) NAs did not work past 120 days without being certified as a nursing aide. This deficient practice was identified for 2 of 3 NAs reviewed (NA#1 and NA#2) who provided direct care to residents on 4 of 4 nursing units. NA#1 was hired on 9/16/24, to provide care to the residents. …
F728 citations in New Jersey
Nursing and Physician Services Deficiencies
Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training.
Data as of , released by CMS on October 8, 2026. Source: CMS Provider Data Catalog.
Against expectation — 2025
New Jersey cites F728 more often than its own record predicts
2.10 times the share F728 takes of citations nationally.
Of every deficiency written in New Jersey in 2025, this is the portion that was F728.
Each state is measured against its own expected share, not against other states.
In the surveyor’s words
What New Jersey surveyors wrote
F728 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 #: NJ182091 Based on interviews and review of other pertinent facility documentation on 4/10/25, it was determined that the facility failed to ensure that a staff member assigned the position of Monitor was not performing direct resident care. This deficient practice was identified for 1 of 3 monitors reviewed and was evidenced by the following: According to the Facility Reportable Event (FRE), a New Jersey Department of Health (NJDOH) document used by healthcare facilities to report incidents with an event date of 1/1/25 revealed the Physical Therapist Aide (PTA) was approached by Resident #4 who stated the aide hit Resident #3. The PTA went to the residents' room, where the aide (Monitor #1) was performing Activities of Daily Living (ADLS) with Resident #3. …
Based on observation, interview and review of pertinent facility documents, it was determined that the facility failed to ensure: a.) verification that recently hired non-certified Nursing Aides (NA) were currently enrolled and actively taking classes in a New Jersey state-approved Certified Nursing Aide (CNA) Training Program, b.) validate completion of Module 1 in their CNA Training Program prior to allocating an independent resident assignment, and c.) there was a delineated policy and/or program in place for the hiring, staffing, and assignments of non-certified NAs for one (1) of one (1) non-certified NA's. …
The short window
Recent years
| Year | Share of New Jersey citations | vs expected |
|---|---|---|
| 2023 | 0.43% | 5.72× |
| 2024 | 0.45% | 6.06× |
| 2025 | 0.14% | 2.10× |
Shares of citations, not counts: earlier years hold fewer inspections.
What else New Jersey surveyors cite →
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