Inspection Reports for
Crest Haven Nursing And Rehabilitation Center

Complaint #2563285 involved failure to develop and implement individualized care plans addressing treatment refusals and preferences, and failure to update care plans for changes in code status. The deficiencies were substantiated with minimal harm and affected a few residents.

The facility failed to develop and implement an individualized comprehensive care plan for a resident who refused treatments and meals, and failed to update another resident's care plan to reflect a change in code status to hospice and DNR/DNI orders. Both deficiencies were identified with minimal harm and affected a few residents.

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.

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.

Complaint #: NJ184231. The complaint alleged failure to notify a resident's family after a change in condition and inadequate respiratory care. The deficiencies were substantiated based on interviews, record reviews, and observations.

The facility failed to notify the family of Resident #178 after changes in condition, lacked physician orders for oxygen administration, and inconsistently administered nebulizer therapy for Residents #178 and #44. Documentation deficiencies and policy gaps were also noted.

Complaint NJ184231 involved failure to notify family of resident condition changes and other care deficiencies.

The facility was found deficient in multiple areas including failure to notify family of resident condition changes, inconsistent urinary catheter care and documentation, lack of physician orders for oxygen, inconsistent nebulizer therapy administration, delayed response to pharmacist recommendations, improper medication storage, and failure to use appropriate personal protective equipment for residents on enhanced barrier precautions.

Complaint numbers NJ00179530 and NJ00180295 triggered the investigation. The facility was found not in substantial compliance based on these complaints.

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.

The complaint investigation found that the facility did not notify the resident's primary physician of the Psychiatric Nurse Practitioner's recommendation for 1:1 supervision after the resident did not contract for safety. The Immediate Jeopardy was identified on 11/21/2024 and removed on 11/22/2024. The noncompliance remained at a level G for actual harm but not Immediate Jeopardy after corrective actions.

The facility failed to notify the resident's primary physician about the Psychiatric Nurse Practitioner's recommendation for 1:1 supervision, resulting in the resident being found in a dangerous situation. Immediate Jeopardy was identified but later removed after the facility implemented corrective actions including staff education and policy revision.

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.

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.

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.

The complaint investigation was substantiated by review of Nurse Staffing Reports, Payroll Based Journal Staffing Data, and Employee Daily Schedules showing no RN coverage on multiple dates. Interviews with the Staffing Coordinator, Director of Nursing, and Licensed Nursing Home Administrator confirmed the deficiency.

The facility failed to ensure RN coverage for 8 consecutive hours daily on multiple dates reviewed, including no RN coverage on specific days in 2022 and 2023. Interviews with staff confirmed the expectation of daily RN coverage, but staffing shortages occurred due to call outs.

The facility was found deficient in multiple areas including failure to provide mail delivery on Saturdays, inadequate investigation and treatment of skin tears for several residents, failure to implement care plan interventions to prevent skin injuries, lack of consistent RN coverage for 8 consecutive hours daily, incomplete annual in-service education and performance evaluations for CNAs, improper labeling and storage of medications and food, and lapses in infection control practices including failure to follow contact isolation protocols and hand hygiene during meal service.

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.

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.

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.

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.