Complete Care at Kresson View

Inspectors wroteBased on observation, interview, and pertinent facility documentation, it was determined that the facility failed to: (a) maintain a homelike environment that was clean, safe, and sanitary, and (b) ensure pantry ice machines were maintained in a sanitary condition. This deficient practice was identified for 4 of 4 units (100-unit, 200-unit, 300- unit, and 400 -unit) and was evidenced by the following: 1.) On 7/29/2025 at 10:39 AM, in room [ROOM NUMBER], the surveyor observed the following: Food in clear packaging on the floor next to the resident’s bed. Foil lid from a juice container on the floor near the radiator. An empty soda bottle, a fork, a used paper towel, and dried liquid spillage were found under the resident’s bed. Brown dried substance on the outer part of the footboard. [...]

Inspectors wroteBased on observation, interview, and review of pertinent records, it was determined that the facility failed to accurately account for and document the administration of controlled medications. This deficient practice was identified on 1 of 5 medication carts (4th floor Cart #1) reviewed and was evidenced by the following:On 7/31/25 at 11:45 AM, the surveyor, accompanied by the Licensed Practical Nurse (LPN #1), reviewed the 4th floor nursing unit's medication cart #1. The following was observed when the declining inventory log was reviewed: Resident #123 should have had 29 tablets of tramadol HCL 50 milligram (mg) (a controlled medication used for pain management), but 28 tablets were on hand. LPN #1 at that time, stated she administered the medication during the morning medication pass (8 AM) and failed to sign it out. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility documents, it was determined that the facility failed to ensure that the resident's dietary preferences were accurately implemented for 1 of 10 residents (Resident #14) reviewed for nutrition, and was evidenced by the following:On 7/31/25 at 12:15 PM, the surveyor observed Resident #14 sitting upright in a geriatric chair (a specialized recliner designed to provide comfort, support, and positioning for individuals with mobility limitations) in the 400 Unit dining room being assisted by the Certified Nurse Assistant (CNA). The resident's diet slip indicated large portions of ground cheesy ham and macaroni casserole, poultry gravy, sauteed spinach with garlic, crustless bread, margarine, vanilla ice cream, chocolate milk, and apple juice. The meal ticket further indicated, No green vegetables. [...]

Inspectors wroteBased on observation, interview and review of pertinent facility documentation, it was determined that the facility failed to follow appropriate infection control practices, specifically the use of Personal Protective Equipment (PPE) during incontinence tours to residents who required Enhanced Barrier Precautions (EBP)(an infection control strategy focused on reducing the spread of multidrug-resistant organisms in nursing homes), to prevent the potential spread of infection in accordance with the Center for Disease Control and Prevention (CDC) guidelines and standards of clinical practice. [...]

Inspectors wroteComplaint #152805, #153069 Based on observations, interviews, review of medical records and other facility documentation, it was determined that the facility failed to ensure: a) there was no delay for physician ordered wound treatment that was not initiated for 17 days, b) Care Plan (CP) interventions to prevent skin breakdown were consistently implemented, c) ensure staff were competent to administer physician ordered wound treatments, and d) a comprehensive assessment was completed to ensure thorough identification of PU risk. The facility also failed to follow the facility pressure ulcer policy to accurately assess and prevent the worsening for a resident assessed as being at risk for pressure ulcers who was initially identified with a full-thickness Stage 3 (tissue loss-fat may be visible) pressure ulcer (PU) to the left gluteus and Stage 2 PU to the sacrum. [...]

Inspectors wroteComplaint #152805 Refer to F677, F697 Based on observation, interview, record review, and review of documentation, it was determined that the facility failed to provide sufficient staff to provide nursing and related services to meet the resident needs. This deficient practice was identified for 5 of 35 residents (Resident #39, #11, #101, #106, and #144), and on 1 of 4 resident units with the potential to affect all residents. This deficient practice was evidenced by the following: Review of the New Jersey Department of Health Long Term Care Assessment and Survey Program Nurse Staffing Report revealed the facility was deficient in (Certified Nurse Aide ) CNA staffing as follows: For the 2 weeks of staffing prior to survey from 12/17/2023 to 12/30/2023, the facility was deficient in CNA staffing for residents on 14 of 14 day shifts as follows: [...]

Inspectors wroteComplaint # 152906 Based on observation, interview, and document review it was determined that the meals were not served at a appetizing temperature and food items were not consistently palatable. The deficient practice was evidenced for 2 of 5 residents who attended a resident council meeting, on 4 of 4 resident units for 2 of 4 food items during a test meal observation, and for Resident #410, #144, #145 and #188. The deficient practice was evidenced by the following: On 01/05/24 at 10:17 AM, the surveyor interviewed Resident #144 about the meals provided. Resident #144 stated, Nothing to desire, food is lousy. On 01/05/24 at 11:00 AM, the surveyor interviewed Resident #410 while in the resident's room. The surveyor asked about the meals provided and the resident stated, the food is horrible. The resident stated, last night was open faced hot turkey with mashed potatoes and gravy. [...]

Inspectors wroteComplaint # 153846 Based on observation, interview and review of facility documentation, it was determined that the facility failed to consistently offer residents evening/bedtime snacks. This deficient practice was identified for 3 of 5 residents (Resident #40, #128, and #142) during resident council meeting and for 4 of 4 nursing units, and was evidenced by the following: On 01/08/24 at 10:30 AM, the surveyor conducted resident council meeting with five residents. During that time, the surveyor inquired about evening/bedtime snacks. Three residents commented that they do not always get offered bedtime snacks and that only those with a physician ordered bedtime snack are given snacks nightly. [...]

Inspectors wroteBased on observation, interview and document review it was determined that the facility failed to ensure the dish machine was operated in a manner to appropriately sanitize, and the large blender was stored appropriately, to limit the potential growth of bacteria and food borne illness. The deficient practice was evidenced by the following: On 01/05/24 at 10:00 AM, the surveyor toured the main kitchen with the Food Service Director (FSD) and observed the dish machine in use to wash tray items which included the tray food trays, insulated food lids and insulated bases. At that time the surveyor interviewed the FSD regarding what the type of dish machine was and how the dishes were sanitized. [...]

Inspectors wroteComplaint # 150996, #153069 Based on observation and interview, it was determined that the facility failed to ensure that the resident dining experience was provided in a manner to promote the dignity and respect for all residents. The facility failed to have a system in place to ensure residents who resided in the same room were able to enjoy and share the meal experience at the same time. This deficient practice occurred on 1 of 4 resident units and for 1 of 1 residents reviewed for dignity related to dining (Resident #11) and was evidenced by the following: On 01/05/24 at 1:26 PM, Resident #11 reported to the surveyor that there were delays in the meal tray being delivered. When asked to elaborate, Resident #11 revealed that dinner would be delivered close to 6:30 PM. [...]

Inspectors wroteComplaint #152906 Based on observation, interview, record review and review of facility provided documents, it was determined the the facility Interdisciplinary Team failed to ensure the facility policy was followed to ensure the Person-Centered Care Plan was revised to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being by including interventions that accurately reflected the resident status and to ensure the resident was involved in the care planning process. The deficient practice was identified for 2 of 35 resident's reviewed for Comprehensive Care Plan (Resident #97 and Resident #101) and was evidenced by the following: a) On 01/10/24 at 8:45 AM, Surveyor #2 observed Resident #97 in their room sitting in a wheelchair. The surveyor observed a large disposable cup that was full of a clear liquid. [...]

Inspectors wroteComplaint # 152805, # 153069 Based on observation, interview, review of records, and review of pertinent documents, it was determined that the facility failed to provide appropriate incontinence care, and personal hygiene care for 3 of 5 residents (Resident #39, #106 and Resident #144) reviewed for Activities of Daily Living (ADL). The deficient practice was evidenced by the following: 1. On 01/05/24 at 11:57 AM, the surveyor observed Resident #39 in bed, the head of the bed was elevated, the resident smiled on approach and was mostly non verbal. The resident's hands were contracted and flexing toward the wrist. The nails were observed to be long and jagged with some yellow coating underneath the finger nails. On 01/09/24 at 9:41 AM, the surveyor observed the resident in bed, smiled when approached and was positioned on the left side. [...]

Inspectors wroteBased on observation, interview, record review, and review of documentation, it was determined that the facility failed to ensure a resident on hemodialysis (artificial means of removing waste from nonfunctioning kidneys) was consistently assessed, documented and monitored before and after hemodialysis treatments. This deficient practice was identified for 1 of 2 residents (Resident #97) reviewed for hemodialysis and was evidenced by the following: On 01/05/24 at 11:05 AM, the surveyor was touring the fourth-floor unit. Resident #97 was not in their room, and the surveyor was informed the resident was out at hemodialysis. On 01/10/24 at 8:45 AM, the surveyor observed Resident #97 in their room. The resident declined to be interviewed at that time. On 01/11/24 at 8:48 AM, the surveyor observed Resident #97 sleeping in their bed. [...]

Inspectors wroteBased on interview and document review, it was determined that facility failed to ensure all medical records remained readily accessible. The deficient practice occurred during an on site survey conducted from 01/05/24 through 01/23/24 and was evidenced by the following: On 01/10/24 at 9:43 AM the surveyor reviewed the closed Electronic Medical Record (EMR) for Resident # 311 and could not locate any rehabilitation notes and on 10:05 AM, the surveyor requested the any additional closed medical records for Resident #311. On 01/10/24 at 11:00 AM, the Licensed Nursing Home Administrator (LNHA) provided the surveyor with a Physical Therapy (PT) and Occupational Therapy dated (OT) Evaluations dated 12/16/21. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility documentation, it was determined that the facility failed to accurately complete the Minimum Data Set (MDS), an assessment tool to facilitate resident care. This deficient practice was identified for 1 of 35 (Resident #49) reviewed for Resident Comprehensive Assessments and was evidenced by the following: On 01/05/24 at 10:51 AM, the surveyor observed Resident #49 in bed. Resident #49 was observed to have a tracheostomy (surgical opening that is made through the front of the neck into the windpipe, or trachea. A curved plastic tube, known as a tracheostomy tube, is placed through the hole allowing air to flow in and out of the windpipe) and an oxygen mask covering the tracheostomy tube. [...]

Inspectors wroteBased on observation, interview, record review, and review of documentation, it was determined that the facility failed to transcribe and document in the Medical Administration Record (MAR) or Treatment Administration Record (TAR) a physician's telephone order for fluid restriction. This deficient practice was identified for Resident #97, 1 of 2 residents reviewed for fluid restriction 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 ensure a resident received pain medication in a timely manner and in accordance with a physician order. This deficient practice was identified for 1 of 2 residents reviewed for pain management (Resident #11) and was evidenced by the following: On 01/10/24 at 8:57 AM, the surveyor observed Resident #11 sitting in a chair in their room and was awake and alert. The surveyor attempted to interview the resident and the resident was holding his/her head and stated that he/she had a splitting headache and that he/she had informed the nurse that he/she would like to have pain medication. The surveyor asked about the resident's pain and the resident stated that the pain was bad and rated the pain as a 10 on a scale of 1 to 10. [...]

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to ensure that all staff were familiar with and adhered to infection control practices in accordance with facility policy guidelines and infection prevention protocol. This deficient practice was identified for 1 of 1 resident reviewed for wound care (Resident #39) and was evidenced by the following: On 01/09/24 at 12:10 PM, the surveyor observed Resident #39 in bed. Also noted on the bedside table was a bottle of Dakins solution (dilute solution use to cleanse wound) and a bottle of wound cleanser on the dresser. On 01/10/24 at 8:30 AM, the surveyor reviewed Resident #39's medical record. The admission Face Sheet (an assessment summary) reflected that Resident 39 was admitted to the facility with diagnoses which included but were not limited to: [...]

Inspectors wroteComplaint # 150996 Based on interview, and review of medical records it was determined that the facility failed to ensure a laboratory value to monitor a therapeutic value for a blood thinner was carried out per physician order which resulted in a sub-therapeutic laboratory value determined upon transfer to the Emergency Department on 12/28/21. This deficient practice occurred for 1 of 1 closed medical records reviewed for physician orders (Resident #311) and was evidenced by the following: On 01/10/24 at 10:05 AM, the surveyor reviewed the closed medical record for Resident # 311 which revealed: a Care Plan dated 12/2021 with a Care Plan Focus for Resident is at risk for injury or complications related to the use of anticoagulation therapy medication: Coumadin (blood thinner), Date Initiated: 12/17/21; Goal: [...]

Inspectors wroteBased on observation, interview, record review, and review of facility documents, it was determined that the facility failed to consistently document catheter care treatments according to physician orders. This deficient practice was identified for 2 of 3 residents (Residents #41 and #114) reviewed for urinary catheters and was evidenced by the following: 1. On 08/27/21 at 9:38 AM and on 08/31/21 at 9:10 AM, the surveyor observed Resident #41 lying in bed asleep, with a catheter bag in place. Review of the Quarterly Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, dated 06/17/2021, included that Resident #41 was cognitively intact, had a diagnosis of obstructive uropathy and had an indwelling catheter. Review of the Physician's Order (PO) Sheets for June, July, and August of 2021 revealed the following orders related to urinary catheter care: [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure medication administration times were sequenced to accommodate a resident's hemodialysis (HD) schedule in accordance with professional standards of practice. This deficient practice was identified for Resident #315, 1 of 1 resident reviewed for hemodialysis, and was evidenced by the following: On 08/25/21 at 11:48 AM, the surveyor observed Resident #315 resting in bed with the head of bed (HOB) slightly elevated. The resident was able to verbalize needs and stated that he/she went to dialysis three times a week. According to the admission Record, Resident #315 was admitted with diagnoses that included, but were not limited to: End Stage Renal Disease (ESRD), dependence on renal dialysis, and Type 2 Diabetes Mellitus with other diabetic kidney complication. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility documents, it was determined that the facility failed to maintain the call bell within reach for one resident. This deficient practice was identified for 1 of 2 residents (Resident #164) reviewed for falls and was evidenced by the following: On 08/25/2021 at 11:50 AM, the surveyor observed Resident #164 lying in bed, with the call bell on the floor. On 08/27/2021 at 9:25 AM, the surveyor observed Resident #164 sitting up on the side of the bed, with the call bell on the floor. On 08/30/2021 at 10:00 AM, the surveyor observed Resident #164 lying in bed with the call bell hanging over the side rail, away from the resident, and pointed down, towards the floor. The resident stated he/she knew how to use the call bell, but that he/she could not locate it to demonstrate the process to the surveyor. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility documents, it was determined that the facility failed to follow professional standards of clinical practice during medication administration. This deficient practice was identified for 1 of 3 nurses on 1 of 3 Units (200 Unit) observed during medication pass 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 state: [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to: a.) apply heel pads to bilateral feet (a cushioned pressure relieving device for feet) and position a pillow between the resident's knees for one resident and b.) ensure that a low air loss mattress (an air mattress designed to prevent and treat pressure wounds) (air mattress) was accurately set in accordance with the physician order for one resident. This deficient practice was identified for 2 of 4 residents (Residents #101 and #161) reviewed for pressure ulcers and was evidenced by the following: 1. During the initial tour of the 300 Unit on 08/25/21 at 1:45 PM, the surveyor observed Resident #101 lying in bed with the head of bed (HOB) slightly elevated. [...]