Crest Haven Nursing and Rehabilitation Center

Inspectors wroteComplaint #2563285 Based on observation, interview, and review of other pertinent facility documents, it was determined that the facility failed to develop and implement an individualized comprehensive care plan (ICCP) for a resident who was non-compliant with receiving treatments and meals prepared in the facility. This deficient practice was identified for 1 of 3 residents sampled (Resident #1) and was evidenced by the following:On 10/30/2025 at 8:30 AM, the surveyor reviewed Resident #1's medical record. A review of the admission Record face sheet reflected the resident had diagnoses that included but not limited to pressure ulcer of the sacral region (stage 4), malignant neoplasm of the rectum (cancer of the rectum), and fracture of the right fibula. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility documents, it was determined that the facility failed to revise an individual Comprehensive Care Plan for a resident with a change in code status. This deficient practice was identified for 1 of 3 residents (Resident #2) reviewed and was evidenced by the following:On [DATE] at 10:05 AM, the surveyor observed Resident #2 in the activities room lying in a recliner. The resident interview was not possible due to a diagnosis of dementia (memory loss). On [DATE] at 12:21 AM, the surveyor reviewed the medical record for Resident #2. A review of the admission Record (an admission summary) reflected Resident #2 was admitted to the facility with medical diagnoses that included but were not limited to; dementia, anxiety disorder, and protein-calorie malnutrition (inadequate intake of protein and calories). [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to ensure that a.) nephrostomy (a type of urinary catheter inserted through the skin into the kidney to drain urine when there is blockage) care was consistently performed and documented in accordance with a physician order; b.) nephrostomy flushing was consistently performed and documented in accordance with a physician order; c.) urine output from nephrostomy tube was consistently monitored and documented according to physician orders; d.) urine output from Foley catheter was consistently monitored and documented according to a physician order; and e.) large catheter bag (a bag used to collect urine) was consistently changed to a leg bag when the resident was out of bed according to a physician order. [...]

Inspectors wroteComplaint #: NJ184231 Based on interview, review of the closed medical record, and review of pertinent facility documents, it was determined that the facility failed to notify a resident's family after a change of condition. This deficient practice was identified for 1 of 21 sampled residents (Resident #178), and was evidenced by the following: The surveyor reviewed the closed medical record for Resident #178. A review of the admission Record face sheet (admission summary) revealed the resident was admitted to the facility with diagnoses including; dementia (a decline of cognitive function) and primary hypertension (high blood pressure). A review of the Progress Notes revealed the following: On 1/20/24 at 6:09 AM, the resident was feeling warm and was noted with a non- productive cough. There was no documentation that the family was notified. [...]

Inspectors wroteComplaint #: NJ184231 Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to a.) ensure there was a physician's order (PO) for oxygen administration and b.) administer nebulizor therapy (a method of delivering medications to the lungs by inhaling a mist created by a nebulizer) consistently according to the physician order. This deficient practice was identified for 2 of 3 residents reviewed for respiratory care and services(Resident #178 and Resident #44), and was evidenced by the following: A review of Resident #178's electronic Medical Record (EMR) revealed two progress notes. On 1/23/2025 at 10:45 AM, and on 1/23/25 at 11:00 AM, which indicated the resident was currently on 2 liters of oxygen. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to respond in a timely manner to the Consultant Pharmacist's (CP) monthly recommendations. This deficient practice was identified for 1 of 5 residents (Resident #16) reviewed for unnecessary medications, and was evidenced by the following: On 4/10/25 at 10:40 AM, the surveyor observed Resident #16 in bed. The resident stated to the surveyor they were taking pain medications because they had three different types of cancer. The resident further explained acetaminophen (Tylenol) usually did not work and after taking it, they would still be in pain. The resident had tried other pain medications like opioids with some success. The surveyor reviewed Resident #16's medical records. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure that all medications used in the facility were labeled and stored in accordance with professional standards to preserve their integrity. This deficient practice was observed in 1 of 2 medication storage rooms (East wing) inspected and was evidenced by the following: On 4/7/25 at 10:42 AM, the surveyor, in the presence of the Licensed Practical Nurse/Unit Manager (LPN/UM #1), inspected the East Unit Medication Room. Observed on the counter was two one-liter opened and removed from the protective packaging Intravenous (IV) solutions for dextrose 5% with 0.45% normal saline (D5/1/2 NS). LPN/UM #1 stated they were for a resident who had been discharged and she was unsure how long the solutions were good for once removed from the protective overwrap. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to ensure that staff wore the appropriate personal protective equipment (PPE) for residents on Enhanced Barrier Precautions (EBP) (designed to reduce transmission 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 infection control practice. This was observed for 1 of 2 unsampled resident (Resident #39) reviewed for EBP. This deficient practice was evidenced by the following: Reference: Use personal protective equipment (PPE) appropriately, including gloves and gown. Wear a gown and gloves for all interactions that may involve contact with the patient or the patient's environment. [...]

Inspectors wroteComplaint #: NJ00179530 Based on interviews, review of the medical records, and other pertinent facility documents on 11/15/24, 11/18/2024, 11/21/2024, and 11/25/2024, it was determined that the facility failed to properly notify a Resident's (Resident #1) Primary Physician (RPP) of a need for increased supervision that was recommended by the Psychiatric Nurse Practitioner (PNP) on 11/6/2024. Resident #1 was on Q (Every) 15 minutes checks that was being done by the staff. The NP recommended 1:1 supervision for one week until the next evaluation because Resident #1 would not contract to safety during the meeting. On 11/9/2024, Resident #1 was found in adjoining in a bathroom standing up with a yellow plastic bag over their head and gripping strings tightly around their neck with their hands. The Resident was transferred to an Acute Care Hospital (ACH) for a crisis evaluation. [...]

Inspectors wroteBased on interviews and record review, the facility failed to provide mail delivery services on Saturdays for residents who resided in the facility. The deficient practice was identified for 5 of 5 residents, (Resident #12, #39, #41, #63, and #72) interviewed during the Resident Council Facility Task (a meeting with residents). The deficient practice was evidenced by the following: On 11/08/2023 at 10:33 AM, during the Resident Council Meeting, the surveyor interviewed Residents #12, #39, #41, #63, and #72 regarding mail delivery services. The five residents reported that the mail was not delivered on Saturdays. On 11/08/2023 at 12:45 PM, during an interview with the surveyor, the Director of Activities stated that residents' mail was delivered to the administrative building (building at a different location from the facility) where it got sorted. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to thoroughly investigate an accident/incident for 3 of 6 residents (Resident #22, #55, and #78) reviewed for accident/incidents. This deficient practice was evidenced by the following: 1.) On 11/03/23 at 10:23 AM, during the initial tour, the surveyor observed Resident #22 sitting in a wheelchair in their room. Resident #22 stated that he/she did not have any complaints about the facility. The surveyor reviewed the medical records for Resident #22. [...]

Inspectors wroteBased on observation, interview, review of medical records and other pertinent facility documentation it was determined that the facility failed to follow professional standards of practice for 2 of 19 residents (Resident #55 and # 195) by not a.) obtaining physicians' orders for treatments for (Resident #55 and #195), b.) providing treatments as ordered by a physician (Resident #55), c.) accurately assessing a resident's skin during weekly skin checks (Resident #55), d.) implementing interventions to protect a resident's skin identified as having frail, fragile skin (Resident #55) and e.) accurately assessing a resident's skin during a admission physical (Resident #195). This deficient practice was evidenced by the following: [...]

Inspectors wroteBased on interview and review of pertinent facility documentation, it was determined that the facility failed to: a.) provide in-service education at least once every 12 months for 2 out of 5 Certified Nursing Aides (CNA)s personnel files reviewed, (CNA#1 and CNA#4) and b.) complete annual performance reviews for 5 out of 5 CNA personnel files reviewed, (CNA#1, CNA#2, CNA#3, CNA#4, and CNA#5). This deficient practice was evidenced by the following: On 11/16/23 at 9:09 AM, the surveyor reviewed the five CNA personnel files which revealed the following: - CNA#1 in-service education was dated 02/10/22. CNA#1 did not receive a performance evaluation. - CNA#2 did not receive a performance evaluation. - CNA#3 did not receive a performance evaluation. - CNA#4 in-service education was dated 02/10/22. CNA#1 did not receive a performance evaluation. [...]

Inspectors wroteBased on observations, interviews, and review of facility documentation it was determined that the facility failed to: a.) ensure that food items were labeled, dated, and stored properly, b.) ensure that ice machines were cleaned and in safe operating condition, and c.) ensure that equipment was cleaned and maintained to prevent foodborne illnesses. This deficient practice was evidenced by the following: On 11/03/23 at 9:56 AM, the surveyor met with the Food Service Director (FSD) to begin the kitchen tour. 1. One gallon opened container of lemon juice was on the shelf on the seasoning rack. The FSD stated that the container did not belong there and it should have been refrigerated. The FSD immediately disposed of the container. 2. [...]

Inspectors wroteBased on observation, interview, and review of medical records and other facility documentation, it was determined that the facility failed to implement Care Plan interventions to reduce the risk for injury for a resident with a known history of skin tears. This deficient practice was identified for Resident #78, 1 of 3 residents reviewed for accidents, and was evidenced by the following: The resident's Face Sheet (FS) indicated that Resident #78 was admitted to the facility with diagnoses that included but were not limited to dysphasia (difficulty swallowing) and Alzheimer's disease. The admission Minimum Data Set (MDS) an assessment tool utilized to facilitate care, dated 08/30/23, indicated that the resident had severe cognitive deficits and required extensive assistance with activities of daily living (ADLs). [...]

Inspectors wroteComplaint NJ #: 157448, 158079, 162538, 162579, 163502 Based on interview and review of the Nurse Staffing Report and Payroll Based Journal (PBJ) Staffing Data Report, it was determined that the facility failed to ensure a Registered Nurse (RN) worked 7 days a week for at least 8 consecutive hours a day for 6 of 13 days reviewed. This deficient practice was evidenced by the following: Review of the Nurse Staffing Report completed by the facility for the week of 08/21/22 to 08/27/22 revealed the facility had no RN coverage for all shifts on 08/24/22 and 08/26/22. Review of the PBJ Staffing Data Report for Quarter 3 2023 (April 1 - June 30) revealed the facility had no RN hours for the following dates: [...]

Inspectors wroteBased on observation, interview, and review of facility documents, it was determined that the facility failed to properly label and date opened multidose medications for 2 of 3 medication carts (West Side 1 and East Side 1) inspected. This deficient practice was evidenced by the following: On 11/09/23 at 10:16 AM, the surveyor inspected the [NAME] Side 1 medication cart in the presence of Licensed Practical Nurse (LPN) #1. Inside the medication cart, the surveyor observed the following: -1 insulin lispro pen which was opened but not labeled with an opened date -1 insulin glargine pen which was opened but not labeled with an opened date At that time, the Assistant Director of Nursing (ADON) verified the insulin pens had been opened but not labeled with an open date. The ADON further stated that the pens should have been dated upon opening and that she would dispose of the insulin pens. [...]

Inspectors wroteBased on observation, interview, medical record review and review of other pertinent facility documentation it was determined that the facility failed to a.) provide a safe environment to prevent the potential spread of infection by not following standards of infection control procedures for 1 of 6 residents reviewed for infection control (Resident #82) from 10/24/23 until 11/06/23, and b.) follow appropriate infection control practices and perform hand hygiene as indicated during dining observation for 1 of 3 units (West Wing) observed. The deficient practice was evidenced by the following: 1.) The surveyor reviewed Resident #82's Face Sheet (FS) which indicated that the resident had the diagnoses which included but was not limited to dementia and aphasia (a disorder that affects how you communicate). [...]