Inspection Reports for
Crystal Lake Healthcare And Rehabilitation

The facility was found deficient in multiple areas including failure to provide a homelike dining environment, untimely completion and transmission of Minimum Data Set (MDS) assessments, failure to develop baseline care plans within 48 hours of admission, inadequate care for residents with contractures, improper catheter care, lack of physician orders for oxygen and suctioning, failure to accommodate resident food preferences, unsafe food handling and storage practices, incomplete arbitration agreement venue specification, and lapses in infection prevention and control practices including hand hygiene and enhanced barrier precautions.

Complaint numbers NJ182091 and NJ185153 were investigated. The facility was found not in substantial compliance with requirements related to abuse, neglect, and staffing. Immediate jeopardy was identified and later removed after corrective actions. The complaint was substantiated based on interviews, medical record reviews, and facility documentation.

The facility was found not in substantial compliance with federal requirements related to abuse, neglect, and staffing. Deficiencies included failure to immediately report and protect residents from observed abuse, inadequate staffing levels, and failure to maintain a quality assurance and performance improvement program. Immediate jeopardy was identified but later removed after corrective actions.

Complaint # NJ185153 involved failure to immediately report and respond to a sexual encounter between two cognitively impaired residents, resulting in immediate jeopardy. The abuse was ultimately unsubstantiated as both residents consented, but the reporting and response were deficient. Complaint # NJ182091 involved a Monitor performing direct care without certification. The complaint investigations included interviews, record reviews, and policy assessments.

The facility failed to ensure immediate reporting and separation of residents involved in a sexual encounter, violating abuse/neglect policies and placing residents in immediate jeopardy. Additionally, a staff member assigned as a Monitor was found performing direct resident care without proper certification. The Licensed Nursing Home Administrator failed to ensure proper implementation of policies and oversight. The facility also failed to maintain documentation for its Quality Assurance and Performance Improvement (QAPI) program.

The complaint investigation was substantiated. The facility failed to prevent abuse of Resident #1 by staff, failed to intervene and report the abuse, and violated resident privacy and confidentiality. Immediate jeopardy was identified and later removed after corrective actions.

The facility was found not in substantial compliance with federal requirements due to failure to prevent abuse of a resident, failure of staff to intervene and report the abuse, and failure to ensure resident privacy and confidentiality. The facility implemented a removal plan, staff education, and audits to address these issues. Immediate jeopardy was removed as of 12/26/2024.

The complaint involved a video showing the Director of Nursing hitting Resident #1 with a broom, recorded by LPN #1 who sent it to a friend who posted it on social media. The incident occurred on 06/20/2023 but was not reported timely to authorities. Staff who witnessed the abuse did not intervene or report it. The Director of Nursing remained employed until suspended on 12/21/2024. The Immediate Jeopardy was identified on 12/23/2024 and removed on 12/26/2024 after the facility implemented a removal plan.

The facility failed to prevent physical and verbal abuse of Resident #1 by the Director of Nursing, failed to intervene by staff who witnessed the abuse, failed to report the incident timely to authorities, and failed to conduct a thorough investigation. The Director of Nursing was suspended and is being terminated. The facility implemented a removal plan including staff education and third-party audits.

The complaint investigation was substantiated with findings of abuse and neglect involving Resident #1 and other residents. Immediate Jeopardy was identified on 10/22/2024 and removed on 10/29/2024 after the facility implemented a Removal Plan and corrective actions. Multiple staff members were terminated or disciplined, and the facility re-educated all staff on abuse policies and incident reporting.

The facility was found not in substantial compliance with requirements related to abuse, neglect, and care plan implementation. Deficiencies included failure to prevent abuse, conduct timely investigations, implement care plans, and maintain adequate staffing levels. Immediate jeopardy was identified but later removed after corrective actions. The facility implemented a Removal Plan, re-educated staff, and initiated audits to monitor compliance.

Complaint #NJ178530 involved allegations of physical abuse of Resident #1 by staff members on 10/14/2024. The police were notified on 10/15/2024. The facility initiated an investigation on 10/15/2024 and suspended involved staff. The investigation was found deficient in timeliness and thoroughness. The Immediate Jeopardy was identified on 10/22/2024 and removed on 10/29/2024 after corrective actions.

The facility failed to prevent physical abuse of Resident #1 by staff members, failed to conduct a timely and thorough investigation, failed to provide accurate witness statements, and failed to implement care plan interventions for Resident #1. The abuse resulted in actual harm including splenic laceration and subcapsular hematoma. The facility also failed to follow its abuse policy and administrator job description.

Complaint investigation based on complaints NJ00172152, NJ00173597, and NJ00173806. The facility was found not in compliance with New Jersey Administrative Code Chapter 8:39 for licensure of long term care facilities due to staffing deficiencies. The facility was required to submit and implement a plan of correction.

The facility was found to be in substantial compliance overall but was cited for failure to meet required minimum staffing ratios on multiple day and overnight shifts, violating New Jersey staffing regulations. The facility implemented a multifaceted corrective plan including staff in-service, recruitment efforts, audits, and ongoing monitoring.

Complaint #: NJ172203. The complaint involved the facility failing to honor the rights of Resident #1 to possess a personal cell phone. The complaint was substantiated based on interviews, record review, and policy review.

The facility failed to honor the rights of one resident to have a personal cell phone in their possession, as the resident's phone was taken away due to frequent 911 calls. The facility acknowledged the deficiency and implemented corrective actions including staff education and audits to ensure compliance with resident rights.

Complaint # NJ172203 regarding the facility's failure to honor Resident #1's right to possess a personal cell phone was substantiated based on interviews and record review.

The facility failed to allow Resident #1 to keep their personal cell phone, which was taken away because the resident used it to call 911 multiple times. The facility acknowledged the issue and stated they would educate the resident to report concerns to staff before calling 911 and would not take the cell phone away in the future.

Complaint numbers NJ164067, NJ166370, NJ166770, NJ169235, NJ170803 triggered the survey. The facility was found not in substantial compliance based on these complaints.

The facility was found not in substantial compliance with multiple regulatory requirements including resident dignity, privacy, abuse prevention, complaint reporting, quarterly assessments, PASARR coordination, advance directives, respiratory care, bedrail use, infection control, and staffing ratios. Deficiencies included failure to maintain dignity during meal assistance, privacy breaches, inadequate abuse investigations and reporting, late quarterly MDS submissions, missing PASARR documentation, incomplete advance directives, unclean respiratory equipment, improper bedrail use, and infection control lapses during medication administration and meal assistance.

The facility was found deficient in multiple areas including failure to maintain resident dignity during feeding, failure to protect resident privacy, failure to prevent and investigate resident-to-resident abuse, failure to timely report incidents to the state, failure to complete timely MDS assessments, failure to submit updated PASARR assessments, failure to maintain accurate advance directives, failure to maintain cleanliness of oxygen concentrators, failure to assess and monitor side rail use properly, and failure to follow infection control protocols including glucometer disinfection and hand hygiene.

The complaint survey was triggered by multiple complaint numbers including NJ00165693, NJ00164145, NJ00164082, NJ00163445, NJ00162420, NJ00159225, NJ00157035, NJ00155008, NJ00154346, NJ00154159, NJ00153728, NJ00153625, NJ00153320, and NJ00151371. The facility was found not in substantial compliance based on these complaints.

The facility was found not in substantial compliance with federal requirements for long term care facilities based on multiple deficiencies including failure to notify resident representatives of condition changes, inaccurate assessments, medication ordering and administration issues, incomplete resident records, and failure to maintain required staffing ratios.

The complaint investigation revealed failures related to notification of a resident's representative about a significant change in condition and hospitalization, inaccurate resident assessment documentation, delayed narcotic medication availability, and incomplete narcotic medication administration records.

The facility failed to notify a resident's representative of a significant change in condition and hospitalization, failed to ensure an accurate Minimum Data Set (MDS) assessment for one resident, and failed to ensure timely ordering and availability of narcotic pain medication for another resident. Additionally, the facility failed to maintain complete and accurate clinical records related to narcotic medication administration.

Deficiencies were cited related to facility cleanliness, comprehensive assessments, care planning, medication monitoring, food safety, environmental safety, and life safety code compliance.

The facility was found deficient in multiple areas including failure to maintain a clean and sanitary environment, untimely completion of resident assessments, incomplete and inaccurate care plans, inadequate monitoring of psychotropic medication, failure to secure laundry chute doors, lack of physician orders for oxygen therapy, improper medication labeling, unsafe food handling and sanitation practices, and incomplete medical records.

Complaint # NJ 145922 involved allegations of staff to resident abuse for Resident #2. The facility failed to report the allegation timely to the Administration and NJDOH. The allegation was investigated but not confirmed. Education on Abuse & Neglect Policy was provided to involved staff and will continue monthly.

The facility was found not in substantial compliance due to failure to timely report an allegation of staff to resident abuse and failure to follow the facility's Abuse & Neglect policy for Resident #2. Additionally, the facility failed to provide proper care and follow the Feeding Tube-Site Care policy for Resident #1.

The visit was complaint-related due to concerns about COVID-19 infection control failures, including failure to identify exposed residents as PUIs and failure to implement appropriate PPE and isolation protocols. Immediate Jeopardy was identified and later removed after corrective actions.

The facility failed to identify all residents exposed to COVID-19 as persons under investigation (PUI) and did not implement appropriate transmission-based precautions (TBP), posing an immediate jeopardy to resident safety. Staff were not consistently using N95 masks or full PPE as required. The facility submitted removal plans and eventually complied with infection control requirements by 1/29/2021.