Inspection Reports for Crest Haven Nursing And Rehabilitation Center
4 Moore Road, Cape May Court House, NJ, 08210
Back to Facility ProfileInspection Report Summary
The most recent inspection on November 19, 2025, did not identify any deficiencies as it was a review of the facility’s Notice of Privacy Practices. Earlier inspections showed a pattern of deficiencies related primarily to staffing levels, notification of resident condition changes, infection control, and life safety code compliance. Complaint investigations substantiated issues with staffing ratios and failure to notify resident representatives and physicians of significant changes. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility’s record shows ongoing challenges with staffing and safety requirements, with no clear improvement trend in recent years.
Deficiencies (last 5 years)
Deficiencies (over 5 years)
8.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
65% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
41% occupied
Based on a April 2025 inspection.
Occupancy over time
Notice
Deficiencies: 0
Date: Nov 19, 2025
Visit Reason
This document serves as a Notice of Privacy Practices informing individuals about how their medical information may be used and disclosed by NJDHSS, the rights they have regarding their health information, and the responsibilities of NJDHSS to protect this information.
Findings
The notice details the types of information covered, reasons for use and disclosure of health information, individuals' rights to access and control their information, legal duties of NJDHSS, and contact information for privacy concerns.
Report Facts
Effective date: 2011
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director, NJDHSS Privacy Officer | Listed as contact person for privacy practices and complaints |
Inspection Report
Annual Inspection
Census: 74
Capacity: 180
Deficiencies: 12
Date: Apr 14, 2025
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities. The survey included complaint investigations and a Life Safety Code Survey.
Complaint Details
Complaint investigation substantiated deficiencies related to failure to notify resident representatives of changes, failure to maintain minimum staffing ratios, and failure to provide required care and services.
Findings
Deficiencies were cited related to notification of changes, bowel/bladder incontinence care, respiratory care, drug regimen review, staffing ratios, life safety code violations including egress doors, fire drills, and elevator maintenance. The facility failed to maintain required staffing levels and proper documentation in several areas.
Deficiencies (12)
Failed to notify a resident's representative after a change of condition.
Failed to ensure appropriate treatment and services for bowel/bladder incontinence.
Failed to provide respiratory care including tracheostomy care and suctioning.
Failed to conduct monthly drug regimen reviews by a licensed pharmacist.
Failed to maintain required minimum nurse staffing ratios.
Failed to maintain clinical security needs and proper locking devices on egress doors.
Failed to conduct quarterly fire drills on each shift as required.
Failed to maintain emergency communication telephone in proper working condition.
Failed to maintain integrity of smoke barrier partitions.
Failed to properly label and store drugs and biologicals.
Failed to establish and maintain an infection prevention and control program.
Failed to ensure staff wore appropriate personal protective equipment (PPE).
Report Facts
Census: 74
Total licensed beds: 180
Deficient staffing shifts: 28
Deficient staffing shifts: 1
Deficient shifts for RN coverage: 147
Required staffing hours: 209.5
Actual staffing hours: 208
Difference in staffing hours: -1.5
Number of residents reviewed for deficient practice: 3
Number of residents reviewed for drug regimen: 5
Number of residents reviewed for pain management: 5
Number of residents reviewed for infection control: 2
Number of residents reviewed for PPE use: 5
Number of residents reviewed for medication storage: 1
Number of exit discharge doors: 20
Number of smoke zones: 9
Number of smoke barrier partitions deficient: 2
Number of elevators tested: 1
Number of fire drills conducted: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Educated on importance of changing catheter drainage bags and documenting treatment administration record |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Interviewed regarding documentation of resident condition changes |
| Director of Nursing | Director of Nursing | Educated staff on medication administration and charting omissions; involved in audits and education on catheter care |
| Staffing Coordinator | Re-educated on staffing regulations and shift ratios | |
| Licensed Nursing Home Administrator | Administrator | Interviewed regarding staffing and facility operations |
| Maintenance Director | Maintenance Director | Removed tubing blocking exit doors and conducted audits on exit discharge doors |
| Unit Manager | Unit Manager | Educated on oxygen administration policy and medication storage |
| Licensed Practical Nurse/Unit Manager (LPN/UM #1) | Licensed Practical Nurse/Unit Manager | Interviewed about medication storage and insulin bottle disposal |
Inspection Report
Complaint Investigation
Census: 76
Deficiencies: 2
Date: Nov 26, 2024
Visit Reason
The inspection was conducted as a complaint investigation based on complaints NJ00179530 and NJ00180295, with survey dates spanning 11/15/2024 to 11/26/2024.
Complaint Details
Complaint numbers NJ00179530 and NJ00180295 triggered the investigation. The facility was found not in substantial compliance based on these complaints.
Findings
The facility was found not in substantial compliance with 42 CFR Part 483, Subpart B, for long term care facilities due to failure to properly notify a resident's physician and representative of significant changes, and failure to ensure staffing ratios were met for 2 of 14-day shifts reviewed. The facility implemented a removal plan of action and conducted staff education and policy revisions.
Deficiencies (2)
Failure to properly notify a Resident's physician and representative of a need for evaluation and changes in status.
Failure to ensure staffing ratios were met for 2 of 14-day shifts reviewed.
Report Facts
Survey Dates: 11/15/2024, 11/18/2024, 11/21/2024, 11/26/2024
Census: 76
Sample Size: 5
Staffing Deficiency: 2
Certified Nurse Aides (CNAs): 9
Residents: 77
Residents: 78
Inspection Report
Annual Inspection
Census: 94
Deficiencies: 9
Date: Nov 17, 2023
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities. The survey included complaint investigations and a review of staffing and life safety code compliance.
Complaint Details
The survey included complaint investigations with complaint numbers NJ #157448, 158079, 162538, 162579, 163502. Deficiencies related to staffing, quality of care, and infection control were substantiated.
Findings
The facility was found to be in substantial compliance with emergency preparedness but had multiple deficiencies including failure to provide mail delivery services on Saturdays, inadequate investigation of incidents, failure to maintain required staffing levels, deficiencies in quality of care, medication storage, infection control, and life safety code violations related to exit signage, fire alarm systems, and sprinkler coverage.
Deficiencies (9)
Failure to provide mail delivery services on Saturdays for residents.
Failure to thoroughly investigate accidents/incidents for residents.
Failure to maintain required minimum direct care staff to resident ratios.
Failure to follow professional standards of practice in resident care.
Failure to properly label and date opened multidose medications.
Failure to implement infection prevention and control program effectively.
Failure to ensure smoke detectors and fire alarm systems were properly maintained and tested.
Failure to provide adequate exit signage and illumination.
Failure to maintain required nurse staffing levels with a Registered Nurse for 8 consecutive hours daily.
Report Facts
Census: 94
Sample Size: 21
Deficiency Count: 9
Staffing Ratios: 1
Staffing Ratios: 1
Staffing Ratios: 1
Missing Exit Signs: 8
Fire Extinguishers: 48
Medication Cart Inspections: 3
Insulin Pens: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Interviewed regarding resident care and incident reporting. |
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Interviewed regarding resident care and medication administration. |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Interviewed regarding resident care and medication administration. |
| Licensed Practical Nurse #4 | Licensed Practical Nurse | Interviewed regarding resident care and medication administration. |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Interviewed regarding resident care and incident reporting. |
| Certified Nursing Assistant #2 | Certified Nursing Assistant | Interviewed regarding resident care and meal tray observations. |
| Certified Nursing Assistant #3 | Certified Nursing Assistant | Interviewed regarding resident care and incident reporting. |
| Director of Nursing | Director of Nursing | Interviewed regarding staffing, incident reports, and corrective actions. |
| Assistant Director of Nursing | Assistant Director of Nursing | Interviewed regarding staffing, incident reports, and corrective actions. |
| Licensed Nursing Home Administrator | Licensed Nursing Home Administrator | Interviewed regarding staffing and facility policies. |
| Staffing Coordinator | Staffing Coordinator | Interviewed regarding staffing ratios and schedules. |
| Director of Human Resources | Director of Human Resources | Interviewed regarding employee files and performance evaluations. |
| Licensed Practical Nurse/ Infection Preventionist | Licensed Practical Nurse/ Infection Preventionist | Interviewed regarding infection control policies and staff education. |
| Food Service Director | Food Service Director | Interviewed regarding kitchen cleanliness and food safety. |
| Maintenance Director | Maintenance Director | Interviewed regarding fire safety inspections and maintenance. |
Inspection Report
Life Safety
Capacity: 115
Deficiencies: 6
Date: Nov 17, 2023
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health on 11/03/2023 and 11/06/2023 to assess compliance with Medicare/Medicaid participation requirements related to fire safety and life safety codes.
Findings
The facility was found noncompliant with several life safety code requirements including missing illuminated exit signs, failure to perform semi-annual inspections of the kitchen range-hood fire suppression system, failure to check smoke detection sensitivity every alternate year, improper installation of sprinklers due to missing ceiling tiles, failure to perform monthly inspections on some portable fire extinguishers, and lack of remote manual stop stations for emergency generators.
Deficiencies (6)
Facility failed to provide four illuminated exit signs to clearly identify exit access paths in two courtyards.
Facility failed to inspect the kitchen range-hood fire suppression system semi-annually as required.
Facility failed to ensure smoke detection sensitivity was checked every alternate year as required.
Facility failed to properly install sprinklers due to missing ceiling tiles allowing heat to bypass sprinklers.
Facility failed to perform monthly examinations for 3 of 48 portable fire extinguishers as required.
Facility failed to install remote manual stop stations for 2 emergency generators as required.
Report Facts
Deficiencies cited: 6
Total resident sleeping rooms: 115
Portable fire extinguishers: 48
Missing ceiling tiles: 8
Semi-annual inspections missed: 1
Inspection Report
Annual Inspection
Census: 81
Deficiencies: 7
Date: Jan 6, 2023
Visit Reason
A Recertification survey was conducted by Healthcare Management Solutions, LLC on behalf of the New Jersey Department of Health to assess compliance with federal and state regulations.
Findings
The facility was found to be in substantial compliance with 42 CFR 483 subpart B; however, several deficiencies were identified related to staffing ratios, life safety code violations including means of egress obstructions, lack of illumination at exit doors, hazardous area door issues, fire alarm system deficiencies, smoke barrier penetrations, and generator maintenance.
Deficiencies (7)
Failed to maintain required minimum direct care staff-to-resident ratios for the day shift on 3 of 14 day shifts reviewed.
Obstructions in the north wing exit corridor reducing clearance to three feet instead of required four feet and locked exit gate.
Lack of illumination above exit doors adjacent to Rooms 323 and 324 on the north wing.
Hazardous areas not protected by self-closing or automatic-closing doors; doors propped open or missing in multiple medical record storage rooms and electrical and soiled linen rooms.
Smoke detectors installed within 16 inches of air supply diffuser instead of required minimum 36 inches in recreation office.
Penetrations in smoke barriers not sealed or protected in multiple locations including maintenance room, bedrooms, nursing office, and other areas.
Failed to ensure weekly inspections for two generators were completed in the past 12 months as required.
Report Facts
Survey Census: 81
Day shifts deficient in CNA staffing: 3
Residents on deficient staffing days: 86
Residents on deficient staffing day: 80
Generator weekly inspection dates missing: 7
Generator weekly inspection dates missing: 24
Inspection Report
Life Safety
Capacity: 78
Deficiencies: 6
Date: Jan 6, 2023
Visit Reason
A Life Safety Code Survey was conducted by the New Jersey Department of Health on 01/06/23 to assess compliance with fire safety and life safety code requirements for participation in Medicare/Medicaid.
Findings
The facility was found not in compliance with several life safety code requirements including means of egress obstructions, lack of illumination at exit doors, hazardous areas lacking self-closing doors, improperly installed smoke detectors, penetrations in smoke barriers, and incomplete generator inspection records. Deficiencies had the potential to affect all residents.
Deficiencies (6)
Obstructions in exit corridors and locked exit gate reducing clearance below required four feet.
Exit doors adjacent to Rooms 323 and 324 lacked illumination.
Hazardous areas lacked self-closing or automatic-closing doors; some doors were propped open or missing.
Smoke detectors installed within 16 inches of air supply diffusers, violating installation requirements.
Penetrations in smoke barriers were not sealed, allowing potential smoke transfer.
Weekly inspections for two generators were not consistently completed or documented over the past 12 months.
Report Facts
Residents potentially affected: 78
Residents potentially affected: 11
Residents potentially affected: 8
Boxes of medical records: 75
Boxes of medical records: 50
Trash container capacity: 100
Generator KW: 600
Generator KW: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Man | Verified obstructions in corridors, locked gates, smoke detector locations, unsealed smoke barrier penetrations, and lack of generator inspections | |
| Maintenance Director | Verified lack of illumination at exit doors and storage conditions | |
| Maintenance Supervisor | Responsible for monitoring compliance and generator log book |
Inspection Report
Complaint Investigation
Census: 90
Deficiencies: 1
Date: Jul 28, 2022
Visit Reason
The inspection was conducted as a complaint investigation (NJ Complaint #150223) to assess compliance with staffing requirements and other regulatory standards at Crest Haven Nursing and Rehabilitation Center.
Complaint Details
Complaint #150223 was substantiated as the facility failed to maintain minimum direct care staffing ratios on multiple day shifts, including specific dates in November 2021 and July 2022. The facility was unable to provide a staffing policy that included minimum staffing requirements at the time of survey.
Findings
The facility was found to be not in compliance with New Jersey Administrative Code 8:39 regarding mandatory access to care due to failure to maintain required minimum direct care staff-to-resident ratios for the day shift on multiple occasions. The facility was in substantial compliance with federal long term care requirements based on this complaint visit.
Deficiencies (1)
Failure to maintain the required minimum direct care staff-to-resident ratios for the day shift on 6 of 14 day shifts reviewed.
Report Facts
Census: 90
Sample size: 5
Deficient CNA staffing days: 6
CNA staffing counts: 10
CNA staffing count: 9
CNA staffing count: 1
CNA staffing count: 9
Inspection Report
Complaint Investigation
Census: 83
Deficiencies: 0
Date: Apr 21, 2021
Visit Reason
The inspection was conducted in response to Complaint# NJ 141004 to assess compliance with regulatory requirements for long term care facilities.
Complaint Details
Complaint# NJ 141004 was investigated and found to be unsubstantiated as the facility was in compliance.
Findings
The facility was found to be in compliance with the requirements of 42 CFR Part 483, Subpart B, based on this complaint visit.
Report Facts
Sample Size: 3
Inspection Report
Routine
Census: 76
Deficiencies: 0
Date: Mar 23, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 5
Inspection Report
Routine
Census: 76
Deficiencies: 0
Date: Jan 13, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices for COVID-19.
Report Facts
Sample size: 5
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