Park Crescent Healthcare & Rehabilitation Center

Inspectors wroteREPEAT DEFICIENCY Based on interview and record review, it was determined that the facility failed to ensure that the residents' primary physician signed and dated monthly physician orders. The deficient practice was observed for 9 of 33 residents reviewed (Resident #3, 6, 9, 14, 17, 65, 76, 87, 180) and occurred over an extended period. The evidence was as follows:1. A review of the hybrid medical record (paper and electronic documentation) for Resident #6 revealed the physician had last signed the resident's monthly physician orders on 7/5/24. 2. A review of the hybrid medical record for Resident #14 revealed the physician had last signed the resident's monthly physician orders on 9/4/23. 3. A review of the hybrid medical record for Resident #76 revealed the physician had last signed the resident's monthly physician orders on 2/20/25. 4. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to assure that the physician responsible for supervising the care of residents conducted face to face visits and wrote progress notes at least every 60 days. This deficient practice continued over several months for 10 of 33 residents (Resident #3, 4, 6, 9, 12, 17, 65, 76, 87, 180) reviewed and was evidenced by the following. 1. A review of physician progress notes documented in the hybrid medical record (paper and electronic documentation) for Resident #6 revealed there were no physician notes written for over 6 months. 2. A review of physician progress notes documented in the hybrid medical record for Resident #76 revealed there were no physician notes written for over 6 months. 3. [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to maintain the dignity of 1 of 33 residents (Resident # 182). The deficient practice was evidenced by the following: On 8/12/25 at 12:45 PM, the surveyor observed Resident #182 in a geri-chair, in the dayroom. In the dayroom, near Resident #182, the surveyors observed 3 other residents and 2 activity staff members in the room as well. Resident # 182, in the geri-chair was observed with no socks on both feet, the resident had a pair of shorts on which were torn and ripped, and the resident's adult brief was exposed. The surveyor observed that the resident's fingernails were curved and about 1/4 inch long extended past the resident's fingertips. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure the resident's call device was readily accessible. The deficient practice was identified for 2 (two) of the 33 residents (Residents #3 and #137) reviewed for reasonable accommodations of needs/preferences. This deficient practice was evidenced by the following: 1. On 8/12/2025 10:39 AM, the surveyor observed Resident #3 in bed awake, unable to answer the surveyor's inquiry. The surveyor observed that the call light was located behind the resident's bedside table. On 8/12/2025 at 12:18 PM, the surveyor interviewed the Licensed Practical Nurse (LPN #1), who stated that the call bell must have been put there by the Certified Nurse Assistant (CNA) when giving care to the resident. The call bell should be placed within the reach of the resident. [...]

Inspectors wroteBased on observation and interview, it was determined that the facility failed to ensure the most recent 3 years of inspection reports were readily accessible in a prominent area to residents and visitors without having to ask for the reports from facility staff. The deficient practice was identified during interview with 7 residents at the resident group meeting and 1 individual staff interview and was evidenced by the following. On 8/14/2025 at 7:59 AM, the surveyor observed signage located next to the 3rd floor elevator which indicated Survey Report inside Nursing Station. The surveyor interviewed a 3rd floor unit nurse inquiring as to the location of the survey report binder. The nurse looked at the nursing station desk and then in an area behind the desk used as a charting room and found the binder on a shelf. [...]

Inspectors wroteBased on observation and interview it was determined the facility failed to maintain the residents' living environment in a clean, sanitary, and homelike manner for 2 resident rooms (Room # 330 and 332) on the 3rd floor. The deficient practice was evidenced by the following:1. During initial tour, on 8/12/25 at 12:00 PM, in room [ROOM NUMBER], the surveyor observed 3 areas with approximately 6 foot long linear area of scratches on the wall between the resident's bathroom door and the sink inside the room, which exposed the sheet rock. The surveyor also observed 3 scratches to the right side of the window sill in the resident's room, and approximately a 10 inch long broken piece to the resident's upper dresser drawer. 2. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) was completed accurately for 1 (one) of 1 resident reviewed for PASARR (Resident #12). This deficient practice was evidenced by the following: On 8/12/2025 at 10:42 AM, the surveyor observed Resident #12 out of bed to the wheelchair, able to answer the surveyor's inquiry. On 8/18/2025 at 11:09 AM, the surveyor reviewed the electronic Medical Record (eMR) of Resident #12, which revealed the following: A review of the admission Record (AR, an admission summary) reflected that Resident #12 was admitted with diagnoses that included but were not limited to schizophrenia (a serious mental health condition that affects how people think, feel, and behave), unspecified, with a start date of 8/3/23. [...]

Inspectors wroteBased on observation, interview, and record review 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, in accordance with federal guidelines for 2 of 32 residents, Resident #307 and #100 reviewed for accuracy for MDS coding. This deficient practice was evidenced by the following: 1. On 2/12/24 at 10:34 AM, the surveyor observed Resident #307 in their room. Resident stated they were new to the facility and currently on hospice care. At 10:45 AM, the surveyor reviewed the Electronic Medical Record (EMAR) for Resident #307, who was documented on the 2/6/24 admission MDS, Section O - Special Treatments, Hospice - No. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to revise a resident's comprehensive care plan to reflect the most current plan of care for 2 of 47 residents reviewed, Resident #5 and Resident #140. This deficient practice was identified by the following: 1.) On 2/12/24 at 1:09 PM, the surveyor observed Resident #5 in the room lying in their bed. The resident was alert and verbally responsive. The surveyor reviewed Resident #5's medical records. The admission Record (AR) reflected that Resident #5 was admitted to the facility on [DATE] with medical diagnoses which included but not limited to Dysphagia, Type 2 Diabetes Mellitus, Hypertension, and Atherosclerosis. [...]

Inspectors wroteComplaint Number: NJ164148 Based on observation, interview, and record review it was determined the facility failed follow standards of practice with regards to: a) following a physician's order for a medication with parameters (Resident #123), b) ensuring 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) (Resident #123), c) documenting the application and placement of heel boots for a resident (Resident #357), and d) ensuring an external urinary catheter drainage canister was covered with a privacy cover (Resident #25). This deficient practice was identified in 3 of 43 resident reviewed. The deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents it was determined that the facility failed to ensure meals were served at a palatable on 1 of 3 units reviewed for food temperatures. The deficient practice was evidenced by the following: On 2/15/24 at 10:52 AM, the surveyor calibrated a state issued digital thermometer via the ice bath method to 32 degrees Fahrenheit (F) in the presence of the Chef Supervisor (CS). At 11:29 AM, the surveyor and CS observed the first food truck arrived on the 2nd floor East Unit. A regular diet consistency tray was identified by the surveyor and LPN #1. This tray was removed from the food truck and placed at the nurse's station in the presence of the surveyor and CS. The CS replaced the resident's tray from the kitchen. At 11:32 AM, the nursing staff began passing out the lunch trays. [...]

Inspectors wroteBased on observation, interview, and review of facility policies, it was determined that the facility failed to maintain proper kitchen sanitation practices as well as store and discard potentially hazardous foods in a manner to prevent food borne illness. This deficient practice was observed and evidenced by the following: On 2/12/24 at 09:29 AM, the surveyor in the presence of the Assistant Food Service Director (AFSD) observed the following during the kitchen tour: 1. On the inside the deli preparation refrigerator the surveyor observed a pink liquid on the bottom shelf, as well as a small container of egg salad with a created date of 2/8/24. The AFSD stated the liquid was melted strawberry ice cream but could not state why the liquid had not been cleaned up. [...]

Inspectors wroteComplaint#: NJ166117 Based on interviews, medical records (MRs), and review of other pertinent facility documentation on 2/16/24 through 2/21/24, it was determined that the facility failed to obtain and administer an antiseizure medication on 07/31/2023, for a resident with a known history of seizure disorder and recent seizure activity. This deficient practice was identified for 1 of 47 residents (Resident #157) reviewed for medication administration. Resident #157 was admitted and needed antizeizure medicine, did not receive the medication, had a seizure and was sent to the hospital via 911 on 8/1/2023. The facility's failure to obtain and administer the antiseizure medication, posed the likelihood of serious harm to the health and well-being of Resident #157. This resulted in an Immediate Jeopardy (IJ) situation. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to: a) ensure that the resident's primary physician accurately dated physician progress notes (PPN) during his visit to ensure that the resident's current medical regimen was up to date and b) ensure that the resident's primary physician wrote PPN at least every 60 days with alternating Nurse Practitioner (NP) visits. This deficient practice was observed for 2 of 47 residents, Resident #147 and Resident #58. This deficient practice was evidenced by the following: 1. On 2/22/24 at 10:51 AM, the surveyor reviewed a closed record for Resident #147 who was admitted to the facility on [DATE] and was discharged to the hospital on 8/1/23. The surveyor further reviewed Resident #147 hybrid medical records. [...]

Inspectors wroteBased on observation, record review, and interview it was determined that the facility failed to provide visual privacy for a resident during a wound treatment. The deficient practice was observed for 1 resident, #61, of 30 reviewed and was evidenced by the following: The surveyor reviewed the medical record of Resident #61 which revealed the following: The 10/7/21 quarterly Minimum Data Set (MDS) assessment tool indicated the resident had long and short-term memory impairment and severely impaired cognitive skills for decision making. Resident #61 was noted to have impaired cognition related to Alzheimer's disease in a care plan initiated 7/15/15 and revised 8/31/21. The surveyor observed the Licensed Practical Nurse (LPN) perform wound treatments to the resident's sacrum and buttock on 10/28/21 at 10:35 AM. [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to follow a physician's order to monitor the blood level of a drug the resident was receiving. This was found with 1 of 33 residents reviewed, Resident # 155. Reference: New Jersey Statues, Annotated Title 45, Chapter. Nursing Board The Nurse Practice Act for the State of New Jersey states; The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual or potential physical and emotional health problems, through such services as case finding, health teaching, health counseling, and provision of care supportive to or restorative of life and well being, and executing a medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to provide a.) resident assessment and monitoring upon return from dialysis for Resident #58 and b.) failed to schedule medications according to dialysis days for Resident #101, 2 of 3 residents reviewed for hemodialysis. This deficient practice was evidenced by the following: 1. The surveyor observed Resident #58 on 10/22/21 at 8:50 AM seated on the side of the bed eating breakfast. The resident refused to be interviewed. A review of the resident's electronic medical record (EMR) revealed the following: The admission Record included the diagnoses of end stage renal disease and dependence upon renal dialysis. The 10/7/21 quarterly Minimum Data Set assessment tool (MDS) indicated that the resident was cognitively intact. [...]

Inspectors wroteBased on record review and interview it was determined that the facility failed to respond and act upon a recommendation from the consultant pharmacist for 1 resident, Resident #101, of 33 reviewed. The deficient practice was evidenced by the following: A review of Resident #101's electronic medical record revealed the following: The October 2021 Clinical Physician Orders (CPO) included an order for dialysis every Monday, Wednesday, and Friday with a pickup time from the facility at 2:00 PM. Three of the medications listed in the October 2021 Medication Administration Record (MAR) were scheduled to be administered at a time when the resident would be out of the facility at the dialysis clinic. They were as follows: [NAME]-Vite (B Complex-Vitamin C-Folic Acid) scheduled for 5:00 PM; Eliquis (anticoagulant) plotted for 6:00 PM; Cyproheptad (appetite stimulant) plotted for 5:00 PM. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to store unopened medications appropriately during and inspection of the medication cart. This deficient practice was observed in 1 of 7 medication carts inspected. The deficient practice was evidenced by the following: 1. On 10/22/21 at 10:26 AM, the surveyor inspected the even side south medication cart in the presence of the Licensed Practical Nurse (LPN). The surveyor observed an unopened bottle of Xalatan eye drops in the top drawer of the medication cart. The manufacturer specifications indicated that the eye drops should be refrigerated until opened. The LPN stated that the medication came here with a resident from the hospital, and it should have been discarded. [...]

Inspectors wroteBased on observation, interview, record review and policy review, it was determined that the facility failed to a.) store potentially hazardous foods in a manner to prevent food borne illness and b.) failed to maintain the kitchen environment and equipment in a sanitary manner to prevent contamination from foreign substances and potential for the development a food borne illness. This deficient practice was evidenced by the following: On 10/21/21 at 10:05 AM, in the presence of the Food Service Director (FSD), the surveyor observed the following: 1. In food preparation area, the surveyor observed the following: [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to follow appropriate measures to prevent and control the spread of infection for: a.) hand hygiene for safe food handling during food preparation; b.) infection prevention during wound treatment observations and c.) infection prevention during medication pass observation. The deficient practices were evidenced by the following: 1. On 10/21/21 at 10:54 AM, in the presence of the Food Service Director (FSD) in the food preparation area in the kitchen, the surveyor observed a Food Service Worker (FSW) wash her hands for 20 seconds, used a paper towel to dry her hands, then took a clean paper towel to turn off the faucet. The FSW used the paper towel to wipe off the sink basin, discarded the paper towel and walked to the food preparation area. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to ensure that the residents primary physician sign and date monthly physician orders to ensure that the residents current medical regimen was appropriate. This deficient practice was observed for 21 of 36 residents (Resident #79, #7, #37, #42, #83, #54, #73, #95, #114, #101, # 157, #57, #58, #60, #130, #9, #65, #69, #124, #362 and #116) reviewed and evidenced by the following: 1. The surveyor reviewed the Physician Orders (PO) for resident #79 which revealed that the physician did not sign and date the monthly PO for the month of September 2021. 2. The surveyor reviewed the PO for resident #7 which revealed that the physician did not sign and date the monthly PO for the months of October 2020 through June 2021, and July 2021 through September 2021. 3. [...]