Crest Pointe Rehabilitation and Healthcare Center

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to: a) maintain kitchen equipment in a clean, safe and sanitary manner and b) maintain proper temperatures and logs for 2 of 2 freezer units on the nursing units. This deficient practice was evidenced by the following:On 9/14/25 at 10:28 AM, in the presence of the Food Service Director (FSD), the surveyor observed the following:1. The can-opener blade had a metal chip on the left side. The FSD acknowledged it had not been changed. The FSD was unable to produce a maintenance log to indicate when the blade should be replaced.2. The microwave had multicolored food debris on the interior ceiling. The FSD acknowledged the debris and agreed that it was not cleaned according to facility policy. 3. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to; a) maintain and clean the interior of 1 of 2, (Bayside), nursing unit ice machines, and b) ensure that clean linen was stored in a manner to prevent contamination, assist in the prevention of infection(s), and be free of dirt, dust and debris as evidenced by the following: On 9/15/2025 at 11:25 AM, the surveyor toured the Bayside unit ice machine with the Licensed Practical Nurse/ Unit Manager (LPN/UM #1). The surveyor observed the ice machine was not clean on the interior of the ice dispenser shoot. The surveyor noted a white sediment and black discoloration on the interior of the ice dispenser shoot. During the tour the LPN/UM #1 stated that it was not cleaned according to facility policy. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility documentation, it was determined that the facility failed to obtain a physician's order for the use of a hand roll (a device used to maintain a resident's hand in a functional position). This deficient practice was identified for 1 of 1 resident (Resident #8) reviewed for positioning and mobility and was evidenced by the following:1.) On 9/14/2025 at 10:11 AM, the surveyor observed Resident #8 resting in bed with their eyes open and holding a hand roll in their left hand. On 9/16/2025 at 8:27 AM, the surveyor reviewed the medical record for Resident #8. A review of the admission Record, an admission summary, revealed the resident had diagnoses which included, but were not limited to: [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to maintain the resident's living environment in a clean, comfortable, homelike manner. This deficient practice was identified on 1 of 2 Nursing units, (Oceanside) observed and reviewed for environmental concerns. This deficient practice was evidenced by the following: On 9/16/24 at 10:24 AM, the surveyor toured the oceanside unit with the Food Service Director (FSD), and observed the following concerns: 1) Resident room [ROOM NUMBER] and the hair salon windows had visible litter throughout a grassy area that had bushes. In the bush line and grass area there was an abundance of litter stuck in branches, under the bushes and on the grass. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility documents, it was determined that the facility failed to ensure that a low air loss mattress was accurately set according to the resident's weight and functioning properly in accordance with a physician's order for a resident who was previously identified to have had an alteration in skin integrity. This deficient practice was identified for 1 of 2 residents (Resident #6) reviewed for pressure ulcers and was evidenced by the following:On 9/14/25 at 9:53 AM, the surveyor observed Resident #6 lying in bed awake. The resident's air mattress pump was observed to be set at a weight of 180 pounds. On 9/14/25 at 11:26 AM, the surveyor observed Resident #6 lying in bed awake. The air mattress pump was set at 180 pounds. [...]

Inspectors wroteComplaint #: NJ177985 Based on observations, interviews, and review of other pertinent facility documentation on 03/28/2025, it was determined that the facility failed to maintain a clean and homelike environment in the common shower rooms, follow their Certified Nursing Assistant job description, follow their Light Housekeeper job description, and follow their cleaning and disinfecting policy. This deficient practice was identified for 2 of 2 units (Oceanside Unit and Bayside Unit), had the potential to affect all residents who used the common shower rooms, and was evidenced by the following: On 03/28/2025 at 11:10 A.M., the surveyor interviewed Resident #3. During this interview the resident stated that the cleanliness of the facility's shower rooms was bad. The resident stated, the shower rooms are bad. Four out of ten for cleanliness. [...]

Inspectors wroteComplaint NJ #: 174364 Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to follow their abuse policies and procedures by ensuring residents were free from verbal abuse. This deficient practice was identified for 2 of 3 residents reviewed for abuse, Resident #60 and #79, and was evidenced by the following: 1. Resident #79, who had diagnoses which included post-traumatic stress disorder (PTSD), anxiety, and depression reported to the Social Worker (SW) on 5/16/24, that Certified Nursing Aide (CNA #1) made sexual comments towards Resident #79 which included CNA #1 stating, bend over; you will like it, and that the resident's messy hair made the resident look sexy. This was witnessed by the nursing aide (NA) and Rehabilitation Director (Rehab Director). [...]

Inspectors wroteComplaint # NJ 173248; 174364 Based on interview, and review of pertinent facility documents, it was determined that the facility's Licensed Nursing Home Administrator (LNHA) failed to ensure staff, as well as himself, implemented the facility's abuse policies and procedures to ensure resident safety and well-being by a.) ensuring Resident #79 was free from verbal sexual abuse and b.) ensure Resident #60 was free from verbal abuse. This deficient practice was identified for 2 of 3 residents reviewed for abuse (Resident #60 and #79). Resident #79, who had diagnoses which included post-traumatic stress disorder (PTSD), anxiety, and depression reported to the Social Worker (SW) on 5/16/24, that Certified Nursing Aide (CNA #1) made sexual comments which included bend over; you will like it; and the resident's messy hair made them look sexy. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure a system was in place that non-certified Nursing Aides (NA) did not continue to work in the facility as a NA past 120 days. This deficient practice was identified for 5 of 5 NAs who worked at the facility for more than 120 days reviewed for sufficient staffing (NA #1, #2, #3, #4, and #5), and was evidenced by the following: During entrance conference on 6/3/24 at 9:17 AM, the surveyor asked the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) how the facility's nurse staffing was, and the LNHA stated it was good; that the facility did not need to use Agency staff. The surveyor asked if the facility used non-certified Nursing Aides (NA), and the LNHA stated they did; [...]

Inspectors wroteComplaint NJ #: 174364 Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to implement their abuse policy to report an allegation of: a.) sexual verbal abuse between a staff member and a resident, and b.) verbal abuse between a staff member and a resident to the New Jersey State Department of Health (NJDOH) within two hours. This deficient practice was identified for 2 of 3 residents reviewed for abuse (Resident #60 and #79), and was evidenced by the following: Refer F600 1. On 6/3/24 at 10:58 AM, Resident #79 reported to the surveyor that Certified Nursing Aide (CNA #1) had made sexual comments towards them, and they refused male aides. The resident stated CNA #1 told them to bend over and they replied, no thank you and CNA #1 stated you will like it. The resident continued on another the day; [...]

Inspectors wroteComplaint NJ #: 174364 Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to implement their abuse policy to thoroughly investigate an allegation of: a.) verbal sexual abuse between a staff member and resident, and b.) verbal abuse between a staff member and resident. This deficient practice was identified for 2 of 3 residents reviewed for abuse (Resident #60 and #79), and was evidenced by the following: Refer F600 1. On 6/3/24 at 10:58 AM, Resident #79 reported to the surveyor that Certified Nursing Aide (CNA #1) had made sexual comments towards them, and they refused male aides. The resident stated CNA #1 told them to bend over and they replied, no thank you and CNA #1 stated you will like it. The resident continued on another the day; CNA #1 stated Don't take this the wrong way but your hair looks sexy that way. [...]

Inspectors wroteBased on observation, interview and review of facility documentation, it was determined that the facility failed to: a.) ensure that staff were trained to properly assess and document care of the hemodialysis access sites which includes the auscultation/palpation of the atrio-ventricular (AV) fistula (a surgical connection connection between an artery and a vein) for bruit (an abnormal sound generated by turbulent arterial blood flow) and thrill (a palpable sensation of blood flow) to assure adequate blood flow and to monitor the hemodialysis access site for bleeding, signs of infection and pain. This deficient practice was identified for 2 of 2 residents reviewed for hemodialysis treatment(Resident #4 and #50) and was evidenced by the following: On 6/6/24 at 10:55 AM, the surveyor observed Resident #50 seated in a wheelchair at the bedside. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined the facility failed to ensure an accurate ordering and receiving of narcotic medications on the required Federal narcotic acquisition forms (DEA 222 forms) were completed with sufficient detail to enable accurate reconciliation for 4 of 10 forms provided. The evidence was as follows: On 6/4/24 at 1:00PM, the surveyor reviewed the facility provided DEA 222 forms which revealed on four of the ten provided forms Part 5, had not been completed upon receipt of the medications from the provider pharmacy as instructed on the reverse of the ordering form. The forms were as follows: Order form number: 231430013; 231430014; 231430015; and 231430016. On 6/7/24 at 10:31 AM, the surveyor and Director of Nursing (DON) reviewed the provided DEA 222 forms. [...]

Inspectors wroteBased on observation and interview, it was determined that the facility failed ensure potentially hazardous food was stored in a sanitary manner. The deficient practice was evidenced by the following: On 6/3/24 at 10:22 AM, the surveyor toured the kitchen with the Food Service Director (FSD) and observed the following: In dry storage, five stacks of boxes containing food and beverage were stored directly on the floor which included a case of fruit cup salad; a case of pear juice; a case of coffee; a case of diced pears; two cases of cranberry juice; and a case of ketchup which were directly on floor. The FSD stated the food was just delivered and usually mats were placed on the floor first. The FSD acknowledged that food should not be stored directly on the floor. At that time, the Regional FSD stated the boxes should have been placed on a mat or palate and not directly on the floor. [...]

Inspectors wroteComplaint NJ #173248 Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to perform proper hand hygiene during wound care to reduce the risk of infection. This deficient practice was identified for 1 of 1 resident reviewed for wound care (Resident #4), and was evidenced by the following: On 6/4/24 at 9:25 AM, Resident #4 was observed lying in bed on an air mattress. Resident #4 refused to be interviewed stating he/she was tired. The surveyor reviewed the medical record for Resident #4. A review of the admission Record face sheet (an admission summary) reflected the resident was admitted to the facility with diagnoses which included but were not limited to; type 2 diabetes mellitus, chronic pain, end stage renal disease, and dependence on renal dialysis. [...]

Inspectors wroteBased on interviews and record review, it was determined that the facility failed to provide the resident or resident representative written notification of the facility's bed hold policy prior to transfer to the hospital for 2 of 4 residents (Resident # 99 and 75) reviewed for hospitalizations. The deficient practice was evidenced by the following: 1. On 4/22/22 at 9:40 AM, the surveyor reviewed the hybrid medical records (paper and electronic) of Resident # 99. The New Jersey Universal Transfer Form (NJUTF) and nurse progress notes revealed that the resident was transferred to the hospital on 2/5/22. [...]

Inspectors wroteREFER to F 610 Based on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to report an allegation of abuse to the New Jersey Department of Health (NJDOH) made by a resident representative who reported the allegation to the Licensed Nursing Home Administrator (LNHA). The resident representative alleged that a staff member had been rude during care of a resident on 4/8/22. This deficient practice was identified for one (1) of two (2) residents reviewed for abuse, (Resident #348) and was evidenced by the following: On 4/21/22 at 10:17 AM, the surveyor interviewed a resident representative (RR) in the room of Resident #348. The RR stated that the resident was recently placed on hospice services and was hoping to take the resident home soon, if possible. [...]

Inspectors wroteREFER to F609 Based on observation, interview, record review and review of pertinent facility documents, it was determined that the facility failed to thoroughly and timely investigate an allegation of abuse reported to the Licensed Nursing Home Administrator by a resident representative. The deficient practice was identified for one (1) of two (2) residents reviewed for abuse (Resident #348 ), and was evidenced by the following: On 4/21/22 at 10:17 AM, the surveyor interviewed a resident representative (RR) in the room of Resident #348. The RR stated that the resident was recently placed on hospice services and was hoping to take the resident home soon, if possible. The RR stated that he/she had an incident during the first week of admission with a Certified Nursing Aide (CNA#2) who had come into the resident's room to render care to the resident. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to accurately code resident's Minimum Data Set (MDS), an assessment tool used to facilitate the management of care. This deficient practice was identified for two (2) of 25 residents, (Resident #16 and Resident #54) reviewed for accurate coding of MDS's and was evidenced by the following: 1. On 4/21/22 at 10:20 AM, the surveyor observed Resident #54 sleeping in bed with his/her eyes closed. The surveyor further observed a sign over the resident's bed that indicated the resident was to wear nonskid socks at all times. The surveyor did not attempt to interview the resident because the resident was observed sleeping. On 4/25/22 at 9:42 AM, the surveyor observed the resident lying in bed. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to a.) follow the appropriate Physician's Order (PO) in accordance with professional standards of practice for the treatment of a pressure ulcer, and b.) follow their facility's Policy and Procedure for Dressings, Dry/Clean. This deficient practice was identified for one (1) of three (3) residents, (Resident #59) reviewed for pressure ulcers and was evidenced by the following: On 4/26/22 at 9:29 AM, the surveyor observed Resident #59 sitting upright at the edge of his/her bed on a functional air mattress eating cheerios for breakfast. The surveyor observed that the resident had light brown adhesive bandages attached to both feet. The brown adhesive bandage on the resident's right foot was dated 4/26. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure that all medications were administered without error of 5% or more. During the medication observation performed on 4/25/22 and 4/26/22, the surveyor observed four (4) nurses administer medications to seven (7) residents. There were 28 opportunities, and three (3) errors were observed which calculated to a medication administration error rate of 10.71 %. This deficient practice was identified for three (3) of seven (7) residents, (Resident #40, #54 and #84), that were administered medications by two (2) of four (4) nurses. The deficient practice was evidenced as follows: 1. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility staff failed to appropriately perform hand hygiene for one (1) of four (4) nurses during the medication pass for one (1) of seven (7) residents being administered medications. These deficient practices were evidenced by the following: According to the U.S. CDC guidelines for Hand Hygiene in Healthcare Settings Hand Hygiene Guidance, updated 1/30/20, included Healthcare personnel should use an alcohol-based hand rub or wash with soap and water for the following clinical indications: [...]

Inspectors wroteBased on observation, interviews and record review, it was determined that the facility failed to notify the resident or resident representative, and the Ombudsman's office in writing for a facility-initiated transfer to the hospital. This deficient practice was identified for five of five resident's, (Resident #41, #45, #75, #85, and #99) reviewed for hospitalization. The deficient practice was evidenced by the following: 1. On 4/22/22 at 9:40 AM, the surveyor reviewed the hybrid medical records (paper and electronic) of Resident # 99. The New Jersey Universal Transfer Form (NJUTF) and nurse progress notes revealed that the resident was transferred to the hospital on 2/5/22. [...]