Cedar Crest/Mountainview Gardens

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to keep the call bell soft pad within residents' reach. This deficient practice was identified for 2 of 22 residents reviewed for accommodation of needs (Resident #57 and #112), and was evidenced by the following: 1. On 01/22/2026 at 11:40 AM, the surveyor observed Resident #57 in their room, with eyes closed, seated in a wheelchair in front of the sink. The surveyor observed that the call bell soft -touch pad (a device used to summon the staff for assistance) was on the bedside table, not within the resident's reach. On 1/23/26 at 9:35 AM, the surveyor observed Resident #57 in their room, with eyes closed, seated in a wheelchair in front of the sink. The surveyor observed that the call bell soft -touch pad was on the bedside table, not within Resident #57's reach. [...]

Inspectors wroteBased on observation, interview, and review of other facility documentation, it was determined that the facility failed to follow appropriate hand hygiene practices during dining observations in 1 of 3 dining rooms (2nd floor) and for 2 of 3 staff members (Certified Nursing Assistant (CNA)) and Registered Nurse (RN) during meal service. This deficient practice was evidenced by the following: According to the CDC Clinical Safety: Hand Hygiene for Healthcare Workers dated 2/27/24, Healthcare personnel should use an alcohol-based hand rub (ABHR) or wash with soap and water for the following clinical indications:Immediately before touching a patient .After touching a patient or the patient's immediate environmentAfter contact with blood, body fluids, or contaminated surfacesImmediately after glove removal. [...]

Inspectors wroteComplaint # 2705112, 2704904 Based on interviews, medical record reviews, and review of other pertinent facility documentation on 1/7/26, it was determined that the facility failed to implement a two -person assistant when transferring Resident #1 from bed to wheelchair in accordance with the resident's care plan. This contributed to the resident exhibiting signs of pain by grimacing, after the inappropriate transfer of the resident from bed to wheelchair by their Certified Nursing Assistant (CNA#1). Further facility assessment of Resident #1 through X-ray report, revealed that the resident sustained right femoral neck fracture (hip fracture). This deficient practice was identified for 1 of 4 residents reviewed (Resident#1). The evident is as followed: [...]

Inspectors wroteComplaint #: NJ185754 Based on interviews, medical record review, and review of pertinent facility documents on 9/18/2025, it was determined that the facility failed to implement their abuse policy and procedure to ensure all residents were protected from abuse when a Dining Associate (DA #1) alleged a Certified Nursing Aide (CNA #1) physically abused a cognitively impaired resident (Resident #1) and did not immediately report the allegation and CNA #1 continued to provide resident care without a thorough investigation. This deficient practice was identified for 1 of 5 residents reviewed for abuse (Resident #1). On 4/19/2025 at approximately 4:45 PM, DA #1 alleged observing CNA #1 feed Resident #1 in the dining room. [...]

Inspectors wroteComplaint #: NJ184124 Based on interviews, record review, and review of other pertinent facility documentation on [DATE] and [DATE], it was determined that the facility failed to follow a resident's (Resident #2) wishes for a Do Not Resuscitate (DNR) status who had a signed Physician's Order (PO) and a Practitioner Orders for Life- Sustainable Treatment (POLST) in their chart when the resident experienced a cardiac arrest on [DATE]. This deficient practice was identified for one resident (Resident #2), and is evidenced by the following: According to the admission Record, Resident #2 was admitted to the facility with diagnoses which included but were not limited to: Dementia (memory loss), Hypertension (a condition in which blood in the artery wall is too high) and Muscle Weakness. [...]

Inspectors wroteComplaint #: NJ184124 Based on interviews, record review, and review of other pertinent facility documentation on 03/11/2025 and 03/12/2025, it was determined that the facility failed to completely fill out a Medical Record (MR) which contained the New Jersey Universal Transfer Form (NJUTF) for a resident (Resident #2) who was sent out to the Hospital. This deficient practice was identified for one resident (Resident #2), and was evidenced by the following: According to the admission Record, Resident #2 was admitted to the facility with diagnoses which included but were not limited to: Dementia (memory loss), Hypertension (a condition in which blood in the artery wall is too high) and Muscle Weakness. [...]

Inspectors wroteBased on observation, interview, and review of facility policies, it was determined that the facility failed to maintain proper kitchen sanitation practices in a manner to prevent food borne illness. This deficient practice was observed and evidenced by the following: On 9/4/24 at 9:21 AM, the surveyor in the presence of the Campus Executive Chef (CEC) observed the following during the kitchen tour: 1. On the preparatory table, the surveyor observed the can opener with a caked on black colored debris. The CEC stated, they were unsure when the can opener was cleaned last, but the can opener would be cleaned immediately. 2. In the cooking area of the kitchen, the surveyor observed the standing dual oven with a sticky yellowish substance and dust like particles on top of the oven. CEC not sure when the oven was last cleaned was last cleaned. 3. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility polices it was determined that the facility failed to: a.) carry out medication orders for a hospice resident and b.) clarify an oxygen order. This deficient practice was identified for 2 of 12 Residents (Resident #67 and #3) reviewed. The deficient practices were 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 the interview and record review, it was determined that the facility failed to code the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care of all residents, accurately for 1 of 25 residents reviewed (Resident # 113). The deficient practice was evidenced by the following: The surveyor reviewed Resident # 113's records. The resident reviewed 1/23/24, was discharged from the facility and according to the Discharge Return Anticipated MDS, an assessment tool used to facilitate the management of care, dated 6/27/24, the Type of Discharge was indicated as unplanned. A review of Resident # 113's progress notes dated 6/18/24, revealed the resident had a planned discharged to an Assisted Living (AL) facility. [...]

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 appropriate use of personal protective equipment (PPE) for 1 of 4 staff observed on 1 of 4 Nursing Units. This deficient practice was evidenced by the following: According to the Center for Disease Control and Prevention (CDC) Clinical Safety: Hand Hygiene for Healthcare Workers dated 02/27/24 revealed: Healthcare personnel should use an alcohol-based hand rub (ABHR) or wash with soap and water for the following clinical indications: Immediately before touching a patient . Before moving from work on a soiled body site to a clean body site on the same patient . [...]

Inspectors wroteBased on interviews and review of electronic medical record, as well as review of pertinent facility documents on [DATE] and [DATE], the facility failed to ensure Certified Nursing Assistant (CNA#1) used a sit to stand lift and a two-person assist transfer in 1 (Resident #1) of 4 residents as determined necessary by the Resident's Holistic Care Plan (HCP). The failure to follow this intervention during the evening care transfer of Resident #1 by CNA #1 resulted in the Resident falling to the floor and became unresponsive subsequently requiring her/his immediate transfer to acute care hospital emergency room (ER) for further evaluation. In the ER, the Resident was found to have large bilateral subdural hematoma (a condition that indicates bleeding in the brain) and expired on [DATE]. The deficient practice was evidenced by the following: [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to notify the resident or the resident's representative in writing for a facility-initiated transfer to the hospital. This deficient practice was identified for 2 of 2 residents (Resident #103 and #111) reviewed for hospitalization discharge. The deficient practice was evidenced by the following: 1. On 5/17/23 at 1:31 PM, the surveyor reviewed the hybrid medical records (paper and electronic) of Resident #103. The medical record revealed that the resident was transferred to the hospital on 3/2/23. According to the Discharge Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 3/2/23, reflected that Resident #103 was discharged to the hospital with a return anticipated to the facility. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to complete a quarterly Minimum Data Set (MDS), an assessment tool, for 1 of 26 residents, Resident # 17, system selected for MDS over 120 days and was evidenced by the following: Reference: The Centers for Medicare and Medicaid (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual classified the Observation (Look Back) Period as the time period over which the resident's condition or status was to be captured by the MDS. The Assessment Reference Date (ARD) referred to the last day of the observation (or look back) period that the assessment covered for the resident. The Quarterly assessment was considered timely if 1). The Assessment Reference Date (ARD) of the Quarterly MDS was within 92 days after the ARD of the previous MDS and; 2). the completion date was no later than 14 days after the ARD. [...]

Inspectors wroteBased on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to develop a comprehensive person-centered care plan for a resident under Hospice care (care for a terminally ill person who's expected to have six months or less to live). This deficient practice was identified for 2 of 4 residents reviewed for Hospice comprehensive person-centered care plans, Resident #21 and Resident #35 and was evidenced by the following: 1. On 5/18/23 at 12:10 PM, the surveyor observed a STOP sign posted right outside Resident #21's room door. There was also signage indicating please keep door closed at all times thank you. On 5/18/23 at 1:53 PM, the surveyor reviewed the hybrid medical records for Resident #21. [...]