Careone at Cresskill

Inspectors wroteBased on the interview, review of the medical record, and review of other pertinent facility documentation, it was determined that the facility failed to include in the written notification of emergency transfer that was provided to the Resident or Resident Representative, the facility's bed hold reserve payment for 3 of 3 residents, (Residents #3, #33 and #93), reviewed for hospitalizations. This deficient practice was evidenced by the following: 1. On 3/12/26 at 12:37 PM, Surveyor #1 (S #1) reviewed the hybrid (electronic and paper) medical records of Resident #3. A review of Resident #3's admission Record or face sheet (AR; [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to ensure 1 of 19 residents (Resident #81) call bell was within reach and able to use to accommodate residents' needs. This deficient practice was evidenced by the following:On 3/12/26 at 11:20 AM, the surveyor observed Resident #81 in their room and observed that the call bell was wrapped around the side rail of the bed while the resident was seated in a specialized wheelchair (w/c) while watching a movie on their tablet. The resident's call bell was not within reach of the resident. The resident was unable to locate their call bell when asked by the surveyor if they could reach their call bell if needed an assistance. [...]

Inspectors wroteBased on interview and review of other facility documentation, it was determined that the facility failed to complete in writing the issued required beneficiary notice for 1 of 3 residents reviewed for Beneficiary Protection Notification, (Resident #106). This deficient practice was evidenced by the following:On 3/17/26 at 10:53 AM, the surveyor reviewed the provided Skilled Nursing Facility (SNF) Beneficiary Protection Notification (SNFBPN) Review completed by the facility for Resident #106, and revealed:-The SNFBPN Review indicated Resident #106 last covered Medicare A day was 10/5/25, and Resident #106 remained in the facility. The SNFBPN Review had an attached Notice of Medicare Non-Coverage (NOMNC) which indicated that the Medicare coverage for skilled nursing services will end on 10/5/25, that was signed by the resident on 10/2/25. [...]

Inspectors wroteBased on observation, interview, review of the medical record, and review of other facility documentation, it was determined that the facility failed to adequately monitor target behavior for the use of a psychotropic medication (med) specifically an antipsychotic med and ensure an antipsychotic med was ordered for an appropriate diagnosis for 1 of 5 residents (Resident #99), reviewed for unnecessary medications. This deficient practice was evidenced by the following: On 3/12/26 at 11:37 AM, the surveyor observed Resident #99 lying in a bed that was low to ground. The surveyor interviewed Resident Representative (RR) about the low bed and she stated that the resident fell two times. [...]

Inspectors wroteBased on interviews and record review, it was determined that the facility failed to complete and transmit the Minimum Data Set Assessment (MDS), an assessment tool used to facilitate the management of care, within 14 days as required, for 1 of 22 residents, (Resident #80), reviewed for MDS, in accordance with federal guidelines. This deficient practice was evidenced by the following:According to the Resident Assessment (RAI) Manual, dated October 2025, RAI-required Assessment Summary, The Discharge MDS assessment return not anticipated, the MDS completion date is the discharge date + 14 calendar days. The Transmission date is MDS Completion date + 14 calendar days. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to accurately complete portions of the Minimum Data Set (MDS), an assessment tool to facilitate the plan of care, to accurately reflect the residents' status as of the Assessment Reference Date (ARD) for 4 of 22 residents reviewed (Resident #7, # 33, #54 and #99). The deficient practice was evidenced by the following: 1. On 3/12/26 at 11:12 AM, Surveyor #1 (S #1) observed Resident #7 asleep on an air mattress bed in their room. On 3/16/26 at 3:38 PM, S #1 reviewed the electronic Medical Records (eMR) which revealed diagnoses which included but were not limited to metabolic encephalopathy (brain dysfunction caused by metabolic disturbances) and fracture of the right femur. [...]

Inspectors wroteBased on observation, interview, record review, and review of other pertinent facility provided documentation, the facility failed to, a.) complete thoroughly the psychoactive medication monthly note and b.) accurately document the target behavior that was being monitored for 1 of 5 residents (Resident #81) reviewed for unnecessary medications in accordance with facility policy and standard of clinical practice. This deficient practice was evidenced by the following:Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, deliver a clean technique for wound treatment, and develop a care plan consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 1 resident reviewed for pressure ulcer (Resident #4). The deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: [...]

Inspectors wroteBased on observations, interviews, record review and review of other pertinent facility provided documentation, the facility failed to ensure that a new intervention was implemented and documented in the resident's care plan, in a timely matter, after a resident's fall, in order to prevent any additional falls for 1 of 1 resident reviewed for falls (Resident #99). This deficient practice was evidenced by the following: On 3/12/26 at 11:37 AM, the surveyor observed Resident #99 lying in a bed that was low to ground. The surveyor interviewed Resident Representative (RR) about the low bed and she stated that the resident fell two times. On 3/12/26 at 1:43 PM, the surveyor asked the Licensed Nursing Home Administrator (LNHA) for any incidents/investigations that Resident #99 had since admission. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure residents who received enteral feeding received care in accordance to standard of practice by failing to document the actual total volume infused, plotted an order for flush accurately, and clarified a continuous order for enteral feed for 1 of 1 resident (Resident #12) reviewed for enteral feeding. This deficient practice was evidenced by the following:On 3/12/26 at 10:46 AM, the surveyor observed Resident #12 in bed with their head of bed elevated receiving enteral feed via pump at 50 ml/hr (milliliters/hour). The pump indicated that the total enteral feed received was 877 ml and there was 323 ml left to be infused. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to post the accurate Nursing Home Resident Care Staffing Report daily for 2 of 5 days. This failure could affect the knowledge of the availability of staff to care for the residents, resident representative, and visitors. This deficient practice was evidenced by the following: On 3/12/26 at 8:19 AM, upon entry into the facility, the surveyor observed a posted Nursing Home Resident Care Staffing Report (NHRCSR) that was posted in the reception area of the lobby, dated 3/11/26, for Day Shift 7:00 AM (7 AM)-3:00 PM (3 PM), for Evening Shift 3 PM-11:00 PM (11 PM), and for night shift 11 PM-7 AM. The NHRCSR reflected current census (total number of residents) of 74 in all shifts. The ratio of Certified Nursing Aide to Residents for 7 AM-3 PM shift was 1:8.2. [...]

Inspectors wroteBased on observation, interview, review of the medical record, and review of other facility documentation, it was determined that the facility failed to ensure that a resident received a monthly medication review (MMR) from a pharmacy consultant (PC) for 1 of 5 residents reviewed for unnecessary medication (Resident #99). This deficient practice was evidenced by the following:On 3/12/26 at 11:37 AM, the surveyor observed Resident #99 lying in a bed that was low to ground. The surveyor interviewed the Resident Representative (RR) about the low bed and she stated that the resident fell two times. [...]

Inspectors wroteBased on observation, interview, and review of pertinent documents, it was determined that the facility failed to ensure that all medications (meds) were administered without error of 5% or more during medication (med) administration, 3 nurses administered meds to 3 residents. There were 25 opportunities for error, 2 errors were observed which calculated to a med administration error rate of 8%. This deficient practice was identified for 1 of 3 residents, (Resident #79), that was administered meds by 1 of 3 nurses that were observed. The deficient practice was evidenced by the following:Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to properly store medication (med) per manufacturer specifications and standards of practice. This deficient practice was identified in 2 of 4 med carts observed in the facility. This deficient practice was evidenced by the following:Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. [...]

Inspectors wroteComplaint #2632945Based on interview, record review, and review of other pertinent documents, it was determined that the facility failed to maintain medical records that were accurate for 1 of 22 residents (Resident #96) reviewed. This deficient practice was evidenced by the following: On 3/16/26 at 11:00 AM, the surveyor reviewed the closed hybrid (electronic and paper) medical record of Resident #96. [...]

Inspectors wroteBased on interview, review of medical record, and review of other pertinent facility documents, it was determined that the facility failed to offer residents an influenza vaccine or document the refusal and reason for ineligibility for the vaccine for 1 of 5 residents reviewed for unnecessary medications (Resident #81). The deficient practice was evidenced by the following:Reference:According to the Centers for Disease Control (CDC) and Prevention, Public Law, dated 5/16/24, Influenza Vaccination Laws for State Long-Term Care Facilities, Flu vaccination laws for patients in long-term care facilities, All long-term care facilities. In New Jersey, long-term care facilities must document evidence of annual vaccination against influenza for each resident. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to ensure a.) sufficient nursing staff and b.) call bells were answered timely for three (3) of three (3) residents (Residents # 11, #32, and 40) during the resident council meeting, and one (1) of one (1) resident (Resident #27) during an interview. This deficient practice was evidenced by the following: On 10/16/24 at 10:00 AM, the surveyor met with the Licensed Nursing Home Administrator (LNHA) for an Entrance Conference meeting. [...]

Inspectors wroteBased on observation, interview, review of medical records, and other pertinent facility documentation, it was determined that the facility failed to a.) follow appropriate hand hygiene and use of personal protective equipment (PPE) practices for two (2) of nine (9) staff (two Licensed Practical Nurses [LPN]), b.) follow appropriate infection control practice during the medication and treatment pass observations for two (2) of six (6) nursing staff (one LPN and one Registered Nurse), and c.) follow isolation precautions for a resident who was on Transmission Based Precautions (TBP) by one (1) of one (1) Housekeeping (HK) staff for Residents #77 to prevent the potential spread of infection in accordance with the Center for Disease Control and Prevention (CDC) guidelines, standards of clinical practice, and facility's policy. This deficient practice was evidenced by the following: [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to accurately code the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, for two (2) of 20 residents, (Residents #15 and #53) reviewed for MDS accuracy, and was evidenced by the following: According to the Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual October 2024, for Use Effective October 1, 2024, revealed: Section B: Hearing, Speech and Vision included Item Rationale. Health-related Quality of Life. Unaddressed communication problems related to hearing impairment can be mistaken for confusion or cognitive impairment. Coding Instructions: Code 0, adequate: No difficulty in normal conversation ., Code 1, minimal difficulty: [...]

Inspectors wroteREPEAT DEFICIENCY Based on observation, interview, record review, and review of other pertinent facility provided documentation, the facility failed to follow the physician orders for one (1) of four (4) residents (Resident #61), by one (1) of four (4) nurses (Registered Nurse) observed during medication administration according to the standard of clinical practice. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: [...]

Inspectors wroteComplaint # NJ177383 Based on observation, interview, record review and review of pertinent facility documents it was determined the facility failed to ensure a.) resident's plan of care was provided and followed during an acute change in condition, b.) the resident's request to be sent to the hospital was honored, and c.) a Registered Nurse obtained a physician's order prior to administering a medication to a resident in accordance with professional standards of clinical practice and the facility's policy and procedure for one (1) of 20 residents, Resident #50, reviewed for quality of care. This deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure a resident's medication times were adjusted to accommodate their dialysis (a clinical purification of blood as a substitute for the normal function of the kidneys) schedule for one (1) of one (1) resident (Resident #26) reviewed for dialysis. This deficient practice was evidenced by the following: On 10/16/24 at 10:29 AM, the surveyor observed Resident #26 resting in bed. The resident was alert and verbally responsive. Resident #26 stated they were receiving physical therapy and went to dialysis. The resident had no concerns with their care. The surveyor reviewed the paper and electronic medical record (EMR) of Resident #26. [...]

Inspectors wroteBased on interview, record review, and review of other pertinent documents, it was determined that the facility failed to maintain accurate medical records. This deficient practice was identified for two (2) of the 20 residents reviewed (Residents #4 and #66). This deficient practice was evidenced by the following: 1. On 10/16/24 at 11:12 AM, the surveyor observed Resident #4 seated in a wheelchair with hoyer pad underneath, with a visitor at the bedside. The resident and the visitor both stated that there were no concerns with care. The surveyor reviewed the hybrid (combination of paper and electronic) medical records of Resident #4 as follows: According to the admission Record (AR; [...]

Inspectors wroteBased on observation, interview, record review, and review of facility provided documents, it was determined that the facility failed to ensure that a Significant Change in Status Assessment (SCSA) was completed for Resident #53. This deficient practice was identified for one (1) of 20 residents reviewed, and was evidenced by the following: According to the CMS's (Centers for Medicare and Medicaid Services) RAI (Resident Assessment Instrument) Version 3.0 Manual, updated October 2024 showed: An SCSA is required to be performed when a resident is receiving hospice services and then decides to discontinue those services (known as revoking of hospice care). The ARD (assessment reference date) must be within 14 days from one of the following: [...]

Inspectors wroteC# NJ00170331 Based on interviews, medical record review, and review of other pertinent facility documents on 1/25/24, it was determined that the facility staff failed to consistently document in the Documentation Survey Report (DSR) the Activities of Daily Living (ADL) status and care provided to the resident according to facility policy and protocol for 2 of 3 residents (Resident #1 and Resident #2) reviewed for documentation. This deficient practice was evidenced by the following: 1. According to the admission Record (AR), Resident #2 was admitted with diagnoses that included but were not limited to: Encephalitis (inflammation of the brain), Cerebral Infarction (disrupted blood flow to the brain), Schizophrenia (chronic brain disorder). [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure a physician order for administration site was followed and clarified in accordance with professional standards of practice. This deficient practice was identified during the medication pass observation for one (1) of three (3) nurses and was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: [...]

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to clarify a Physician's Order (PO) for oxygen administration in accordance with professional standards of practice for 1 of 5 residents who received respiratory care (Resident # 28) reviewed. The deficient practice was evidenced by the following: 1. On 7/11/23 at 11:52 AM, the surveyor observed Resident #28 in bed with a tracheostomy and oxygen infusing at 4 Liters Per Minute (LPM.) On 7/13/23 at 11:47 AM, the surveyor observed Resident #28 in bed with a tracheostomy and oxygen infusing at 4 LPM. On 7/14/23 at 9:23AM, the surveyor observed Resident #28 in bed with a tracheostomy and oxygen infusing at 4 LPM. Review of Resident # 28's medical record revealed that the resident was admitted with diagnoses which included Acute Respiratory Failure. [...]

Inspectors wroteBased on observation, interview and review of other pertinent facility documentation, it was determined that the facility failed to remove an expired controlled drug (Restoril) from the active inventory of the back up controlled drug supply. This deficient practice was identified for 1 of 1 back up supply storage device and was evidenced by the following: On [DATE] at 10:06 AM, the surveyor interviewed the Director of Nursing (DON) and Assistant Director of Nursing (ADON) regarding the electronic back up supply machine. The DON stated that the machine contained a back up supply of controlled drugs (CD) and that the CD were inventoried by the nurses every shift which included doing a physical count and checking expiration dating. [...]

Inspectors wroteBased on observation, interview, record review and other pertinent facility documents it was determined that the facility failed to document attempted non-drug interventions and the need for an as needed (PRN) psychoactive medication (Ativan) to be administered. The deficient practice was identified for one (1) of five (5) residents reviewed for unnecessary medications, (Resident #46) and was evidenced by the following: On 7/11/23 at 12:02 PM, the surveyor observed Resident #46 in the Rehabilitation room participating in physical therapy. On 7/12/23 at 12:37 PM, the surveyor attempted to interview Resident #46, but the resident refused to answer any questions. [...]