Inspection Reports for
Careone At Cresskill

Complaint # NJ177383 involved Resident #50 who experienced an allergic reaction. The complaint was substantiated with findings that the nurse failed to obtain a physician's order before administering Benadryl, did not notify the Director of Nursing or resident representative, and did not send the resident to the hospital despite the resident's request. The nurse was suspended and resigned prior to termination.

The facility failed to ensure appropriate treatment and care according to orders and resident preferences for Resident #50 during an allergic reaction event. The nurse administered medication without a physician's order, did not notify the Director of Nursing or resident representative timely, and did not send the resident to the hospital despite the resident's request. The nurse involved was suspended and resigned prior to termination. The facility conducted an investigation, provided staff education, and acknowledged policy violations.

The facility was found deficient in multiple areas including failure to complete a Significant Change in Status Assessment for a resident, inaccurate Minimum Data Set coding, failure to follow physician medication orders, failure to honor a resident's request for hospital transfer, medication timing not adjusted for dialysis schedules, insufficient nursing staff and delayed call bell responses, inaccurate medical records, and lapses in infection prevention and control practices including hand hygiene and PPE use.

The survey included investigations of complaints NJ#171778, #172937, and #177383. Findings included failure to provide adequate care, failure to follow physician orders, failure to maintain staffing ratios, and failure to ensure resident rights. The facility was found to have repeat deficiencies related to these complaints.

The facility was found to have multiple deficiencies including failure to ensure accurate comprehensive assessments after significant changes, failure to meet professional standards in care plans and medication administration, insufficient nursing staff, inadequate infection control practices, and fire safety code violations. Deficiencies were cited in areas such as assessment accuracy, medication administration, quality of care, infection prevention, resident rights, staffing, and life safety code compliance.

Complaint #: NJ00172714. The facility was found to be deficient in CNA staffing for residents on 14 of 14 day shifts and deficient in total staff for residents on 1 of 14 overnight shifts. The facility was found to be in substantial compliance overall based on this complaint visit.

The facility was found not in compliance with New Jersey Administrative Code staffing requirements, failing to meet minimum staff-to-resident ratios for Certified Nurse Aides (CNAs) on 14 of 14 day shifts and total staff on 1 of 14 overnight shifts during the review period.

The facility staff failed to consistently document ADL care, particularly bed mobility assistance, for two residents during multiple shifts in December 2023 and January 2024. Interviews with staff confirmed that documentation was expected but was incomplete, indicating a deficiency in following the facility's charting and documentation policy.

Complaint #NJ00170331 was substantiated based on findings of deficient documentation and staffing issues.

The facility was found not in substantial compliance due to failure to consistently document resident care in medical records, specifically regarding resident-identifiable information and documentation of care provided or refused. Additionally, staffing ratios were deficient for Certified Nurse Aides (CNAs) on multiple day shifts.

The facility was found deficient in multiple areas including failure to follow and clarify physician orders for medication administration sites, failure to clarify oxygen administration orders, failure to remove expired controlled drugs from backup supply, and failure to document non-drug interventions and behaviors related to PRN psychoactive medication administration. All deficiencies were assessed as causing minimal harm or potential for actual harm affecting a few residents.

The facility failed to follow appropriate hand hygiene practices for 1 of 2 nurses observed administering medication to 2 of 5 residents, with deficiencies noted in proper hand washing technique and glove use.

The facility was found deficient in infection prevention and control practices, specifically failing to follow appropriate hand hygiene practices during medication administration by one nurse to two residents.

The facility was found to be in noncompliance due to failure to ensure that exit discharge paths were provided with two sources of lighting. Specifically, one of two exit discharges in the building's basement had only a single-bulb light fixture without a secondary light source, posing a safety risk if the single bulb failed.