Inspection Reports for
Park Crescent Healthcare and Rehabilitation Center
NJ, 07017
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
12.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
140% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
20
15
10
5
0
Occupancy
Latest occupancy rate
17% occupied
Based on a August 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Notice
Deficiencies: 0
Date: Nov 19, 2025
Visit Reason
This document serves to inform individuals about the privacy practices of NJDHSS, including how their medical information may be used and disclosed, and their rights related to 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, and the legal duties of NJDHSS to protect privacy.
Report Facts
Effective date: 2011
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director, NJDHSS Privacy Officer | Contact person for privacy practices and rights |
Inspection Report
Routine
Census: 33
Deficiencies: 7
Date: Aug 20, 2025
Visit Reason
The inspection was a routine regulatory survey conducted to assess compliance with healthcare facility regulations and standards.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity, call light accessibility, availability of survey reports to residents, maintenance of living environment, accurate PASARR screening, timely physician signatures on orders, and timely physician face-to-face visits and progress notes.
Deficiencies (7)
Failure to maintain the dignity of 1 of 33 residents, evidenced by inappropriate clothing and untrimmed nails.
Failure to ensure residents' call devices were readily accessible for 2 residents.
Failure to ensure the most recent 3 years of inspection reports were readily accessible to residents and visitors.
Failure to maintain residents' living environment in a clean, sanitary, and homelike manner for 2 resident rooms.
Failure to ensure accurate PASARR screening for 1 resident with schizophrenia.
Failure to ensure residents' primary physician signed and dated monthly physician orders for 9 residents over an extended period.
Failure to assure physicians conducted face-to-face visits and wrote progress notes at least every 60 days for 10 residents.
Report Facts
Residents reviewed: 33
Residents affected: 1
Residents affected: 2
Residents affected: 2
Residents affected: 1
Residents affected: 9
Residents affected: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) | Interviewed regarding resident nail care and call light accessibility | |
| Director of Nursing (DON) | Discussed concerns about resident nail care, call light accessibility, and physician documentation | |
| Licensed Nursing Home Administrator (LNHA) | Met with surveyors to discuss concerns | |
| Social Worker (SW) | Interviewed regarding PASARR screening accuracy | |
| Licensed Practical Nurse/Unit Manager (LPN/UM) | Interviewed regarding call light accessibility and physician documentation |
Inspection Report
Complaint Investigation
Census: 82
Deficiencies: 0
Date: Apr 29, 2025
Visit Reason
The inspection was conducted as a complaint investigation based on complaint number NJ00185581.
Complaint Details
Complaint #: NJ00185581. The facility is in substantial compliance based on this complaint visit.
Findings
The facility was found to be in substantial compliance with the requirements of 42 CFR Part 483, Subpart B, for long term care facilities based on this complaint visit.
Report Facts
Sample Size: 3
Inspection Report
Complaint Investigation
Census: 170
Deficiencies: 1
Date: Apr 8, 2025
Visit Reason
The inspection was conducted as a complaint investigation based on complaints NJ00182618 and NJ00175276 regarding staffing ratios and compliance with state regulations.
Complaint Details
Complaint numbers NJ00182618 and NJ00175276 triggered the investigation. The facility was found deficient in CNA staffing ratios on multiple shifts but no residents were identified as affected by the deficient practices. The facility was required to submit a Plan of Correction to address these deficiencies.
Findings
The facility was found not in compliance with New Jersey Administrative Code 8:39 standards for licensure of Long Term Care Facilities due to deficient CNA staffing ratios on multiple shifts during specified periods. The facility was in substantial compliance with federal requirements but failed to meet state minimum staffing requirements.
Deficiencies (1)
Failure to ensure staffing ratios were met for CNA staffing during the weeks of 06/30/2024 to 07/06/2024, 01/12/2025 to 01/18/2025, and 03/23/2025 to 04/05/2025, with CNA shortages on multiple day shifts.
Report Facts
CNA staffing deficiency: 1
CNA staffing deficiency: 3
CNA staffing deficiency: 3
Census: 167
CNA staff: 18
Required CNA staff: 21
Census: 176
CNA staff: 15
Required CNA staff: 22
CNA staff: 20
Required CNA staff: 22
CNA staff: 21
Required CNA staff: 22
Census: 171
CNA staff: 17
Required CNA staff: 21
Census: 169
CNA staff: 16
Required CNA staff: 21
Census: 169
CNA staff: 17
Required CNA staff: 21
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Feb 22, 2024
Visit Reason
The inspection was conducted based on a complaint regarding the facility's failure to obtain and administer antiseizure medication to a resident with a known seizure disorder, leading to an immediate jeopardy situation. Additional concerns included failure to ensure timely and accurate physician progress notes for residents.
Complaint Details
Complaint #NJ166117 involved failure to administer antiseizure medication to Resident #157, resulting in an Immediate Jeopardy situation. The complaint was substantiated based on interviews, medical records, and facility documentation.
Findings
The facility failed to administer antiseizure medication to Resident #157 on 07/31/2023, resulting in a seizure and hospital transfer, constituting an Immediate Jeopardy. The facility also failed to ensure that physician progress notes were accurately dated and documented at required intervals for Residents #147 and #58, with multiple late entries and missing notes.
Deficiencies (2)
Failure to obtain and administer antiseizure medication to Resident #157, resulting in immediate jeopardy to resident health or safety.
Failure to ensure physician progress notes were accurately dated and documented at required intervals for Residents #147 and #58.
Report Facts
Residents reviewed for medication administration: 47
Residents reviewed for physician progress notes: 47
Physician progress notes late entries: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Regional Nurse Consultant | Acknowledged Resident #157 had a physician order but did not receive medication | |
| Director of Nursing (DON) | Acknowledged issues with medication administration and physician progress notes | |
| Facility provider pharmacist | Confirmed medication delivery timing and administration requirements | |
| Registered Nurse (RN) supervisor | Involved in evaluation of Resident #157 during seizure | |
| Licensed Practical Nurse (LPN) #2 | Provided information about Resident #58's physician visits and documentation | |
| Physician #2 | Physician | Interviewed about visits and progress notes, acknowledged documentation requirements |
Inspection Report
Routine
Deficiencies: 7
Date: Feb 22, 2024
Visit Reason
The inspection was a routine survey to assess compliance with federal and state regulations regarding resident assessments, care planning, medication administration, food service, and kitchen sanitation.
Findings
The facility was found deficient in accurately coding Minimum Data Set (MDS) assessments for hospice and anticoagulant medications, revising comprehensive care plans to reflect current resident needs, documenting application and placement of heel boots, ensuring privacy covers on external catheter suction devices, following medication orders with parameters and adjusting medication times for dialysis, maintaining proper food temperatures during meal delivery, and maintaining proper kitchen sanitation and food storage practices.
Deficiencies (7)
Failed to accurately code the Minimum Data Set (MDS) for hospice status and anticoagulant medication for residents.
Failed to revise residents' comprehensive care plans to reflect the most current plan of care for 2 residents.
Failed to document application and placement of bilateral heel boots for a resident as ordered.
External catheter suction device lacked a privacy cover and suction tubing was undated.
Failed to follow physician's order for medication with parameters and failed to adjust medication times to accommodate dialysis schedule for a resident.
Meals were served at temperatures below safe and palatable levels due to prolonged tray delivery times.
Failed to maintain proper kitchen sanitation and food storage practices, including presence of melted liquid not cleaned, expired egg salad, dusty light fixtures and fans, and missing caps on chemical bottles.
Report Facts
Residents reviewed for MDS coding accuracy: 32
Residents reviewed for care plan revision: 47
Opportunities for heel boot placement checks missed: 68
Food temperature measurements: 117.9
Food temperature measurements: 60.3
Food temperature measurements: 58.2
Food temperature measurements: 63.1
Food temperature measurements: 94.6
Food temperature measurements: 101.4
Food temperature measurements: 93.1
Food temperature measurements: 95.2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #3 | Licensed Practical Nurse | Confirmed lack of privacy cover and undated suction tubing for Resident #25. |
| LPN #2 | Licensed Practical Nurse | Acknowledged failure to document vital signs during medication administration and failure to adjust medication times for dialysis for Resident #123. |
| Director of Nursing | Director of Nursing (DON) | Provided policies, acknowledged deficiencies, and participated in interviews regarding MDS coding, care plans, medication administration, heel boot documentation, catheter privacy covers, and food service. |
| Licensed Nursing Home Administrator | Licensed Nursing Home Administrator (LNHA) | Participated in interviews and meetings regarding deficiencies and corrective actions. |
| Regional Nurse Consultant | Regional Nurse Consultant (RNC) | Participated in interviews and meetings regarding deficiencies and corrective actions. |
| Assistant Food Service Director | Assistant Food Service Director (AFSD) | Observed kitchen sanitation issues and provided explanations during kitchen tour. |
| Chef Supervisor | Chef Supervisor (CS) | Observed and discussed food temperature issues during meal delivery. |
Inspection Report
Complaint Investigation
Census: 160
Deficiencies: 11
Date: Feb 22, 2024
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long-Term Care Facilities. Complaint investigations were also completed during this survey.
Complaint Details
Complaint #s: NJ00170384, NJ00164200, NJ00170066, NJ00166117, NJ00165047, NJ00164947, NJ00164148, NJ00163966, NJ00162449. The complaint investigations were completed during the survey.
Findings
Deficiencies were cited including an Immediate Jeopardy for failure to obtain and administer a critical medication for a resident with a known condition. Additional deficiencies included inaccurate Minimum Data Set (MDS) coding, failure to revise care plans, failure to meet professional standards in medication administration, incomplete physician progress notes, improper food temperature management, unsanitary food storage, and life safety code violations related to fire safety and electrical systems.
Deficiencies (11)
Failure to obtain and administer an antiseizure medication for a resident with a known seizure disorder, resulting in Immediate Jeopardy.
Inaccurate coding of Minimum Data Set (MDS) assessments for residents, including failure to reflect hospice care and medication use accurately.
Failure to revise residents' comprehensive care plans to reflect current conditions and treatments.
Failure to follow professional standards in medication administration, including documentation and timing adjustments for dialysis residents.
Failure to ensure physician progress notes were accurately dated and documented at least every 60 days with alternating nurse practitioner visits.
Failure to serve meals at safe and palatable temperatures, with delays in meal delivery causing temperature loss.
Failure to maintain proper kitchen sanitation and food storage practices, including cleaning light fixtures, discarding expired food, and proper chemical storage.
Failure to ensure exit stairwell doors were capable of maintaining 2-hour fire resistance rating due to doors not self-closing and latching properly.
Failure to install required fire sprinklers in the top landing of the center stairwell.
Failure to provide Ground-Fault Circuit Interrupter (GFCI) protection for electrical outlets located within 6 feet of water sources in multiple locations.
Failure to install a remote manual stop station for the emergency generator.
Report Facts
Census: 160
Sample Size: 47
Deficiencies cited: 11
CNA staffing: 19
CNA staffing: 19
CNA staffing: 19
CNA staffing: 19
CNA staffing: 20
CNA staffing: 17
CNA staffing: 15
Food temperature: 117.9
Food temperature: 60.3
Food temperature: 58.2
Food temperature: 63.1
Food temperature: 94.6
Food temperature: 101.4
Food temperature: 93.1
Food temperature: 95.2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Acknowledged failure to document vital signs during medication administration for Resident #123 |
| Physician #2 | Primary Physician | Interviewed about physician visit documentation and acknowledged requirement to document progress notes |
| Maintenance Director | Responsible for repairs of fire doors, inspection of GFCI outlets, installation of remote manual stop station, and conducting biannual inspections | |
| Director of Nursing | Responsible for staff education and monitoring corrective actions | |
| Assistant Director of Nursing | Provided education to licensed nursing staff on medication policies and change in condition policy | |
| Chef Supervisor | Responsible for food temperature monitoring and dietary staff education | |
| Licensed Nursing Home Administrator | Responsible for education and monitoring of staffing ratios and fire safety corrective actions |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Feb 23, 2023
Visit Reason
The inspection was conducted based on complaints alleging failure to timely report suspected abuse for Resident 2 and failure to activate emergency medical services for Resident 3 following an accident.
Complaint Details
Complaint #NJ00153326 involved failure to report suspected abuse for Resident 2; the allegation was investigated and determined unsubstantiated. Complaint #NJ00156153 involved failure to activate emergency medical services for Resident 3 after a fall; Resident 3 was transferred via non-emergency transport and later died following surgery for a tibial fracture.
Findings
The facility failed to report an allegation of potential abuse for Resident 2 and failed to activate emergency medical services (911) for Resident 3 after a fall, resulting in delayed medical treatment. Investigations determined the abuse allegation for Resident 2 was unsubstantiated. Resident 3 sustained a fall resulting in a tibial fracture and subsequent death after surgery.
Deficiencies (2)
Failure to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities for Resident 2.
Failure to activate emergency medical services for Resident 3 after a fall, delaying medical treatment.
Report Facts
Complaint number: 2
Resident 2 discharge date: 2022
Resident 3 fall date: 2022
Resident 3 death date: 2022
EMS transport call time: 90
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Investigated abuse allegation for Resident 2 and determined it unsubstantiated; confirmed failure to activate 911 for Resident 3 |
| Registered Nurse 2 | Registered Nurse (RN) 2 | Provided statement regarding abuse allegation incident involving Resident 2 |
| Certified Nursing Assistant 2 | Certified Nursing Assistant (CNA) 2 | Alleged abuse by staff involving Resident 2 |
| Unit Manager 4 | Unit Manager (UM) 4 | Notified of Resident 3 fall and coordinated care and transfer |
| Licensed Practical Nurse 1 | Licensed Practical Nurse (LPN) 1 | Notified of Resident 3 fall and assisted with care |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Assessed Resident 3 after fall and involved in transport coordination |
| Social Services Director | Social Services Director (SSD) 1 | Witnessed Resident 3 on floor after fall and notified nursing staff |
Inspection Report
Complaint Investigation
Census: 164
Deficiencies: 2
Date: Feb 23, 2023
Visit Reason
A complaint survey was conducted by Healthcare Management Solutions, LLC on behalf of the New Jersey Department of Health due to allegations of abuse and quality of care concerns involving specific residents.
Complaint Details
Complaint # NJ00153326 involved failure to report alleged abuse for Resident 2. Complaint # NJ00156153 involved failure to activate emergency medical services for Resident 3 after a fall.
Findings
The facility was found not to be in substantial compliance with 42 CFR 483 subpart B. Deficiencies included failure to report an allegation of potential abuse for one resident and failure to activate emergency medical services promptly for another resident after a fall.
Deficiencies (2)
Failure to report an allegation of potential abuse to the State Survey Agency for one of four residents reviewed for abuse.
Failure to activate emergency medical services for one resident reviewed for accidents and incidents, potentially delaying medical treatment.
Report Facts
Sample Size: 12
Supplemental Residents: 0
Deficiencies cited: 2
Audit frequency: 3
Audit frequency: 4
Audit frequency: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Named in investigation and corrective action related to abuse allegation and emergency medical service activation |
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Educated staff on abuse policy and involved in abuse allegation investigation |
| Registered Nurse 1 | Registered Nurse (RN) | Provided employee statement regarding abuse allegation |
| Registered Nurse 2 | Registered Nurse (RN) | Provided employee statement regarding abuse allegation |
| Licensed Practical Nurse 1 | Licensed Practical Nurse (LPN) | Documented progress notes related to resident fall |
| Unit Manager 4 | Unit Manager | Involved in fall investigation and follow-up |
| Social Services Director 1 | Social Services Director (SSD) | Witnessed resident on floor after fall and notified nurse |
Inspection Report
Routine
Census: 157
Deficiencies: 0
Date: Dec 29, 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
Deficiencies: 8
Date: Nov 5, 2021
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident privacy, medication administration, dialysis care, physician order documentation, medication storage, food safety, and infection control practices at Park Crescent Healthcare & Rehabilitation Center.
Findings
The facility was found deficient in multiple areas including failure to provide visual privacy during wound treatment, failure to follow physician orders for medication monitoring, inadequate dialysis care and medication scheduling, lack of physician signatures on monthly orders, improper medication storage, unsanitary kitchen conditions, and breaches in infection prevention and control practices.
Deficiencies (8)
Failed to provide visual privacy for a resident during wound treatment.
Failed to follow a physician's order to monitor the blood level of a drug for a resident.
Failed to provide safe, appropriate dialysis care and medication scheduling for residents receiving dialysis.
Failed to ensure residents' primary physicians signed and dated monthly physician orders.
Failed to respond and act upon a consultant pharmacist's recommendation regarding medication administration times for a resident.
Failed to store unopened medications requiring refrigeration appropriately in the medication cart.
Failed to store potentially hazardous foods properly and maintain kitchen environment and equipment in a sanitary manner.
Failed to provide and implement an infection prevention and control program, including proper hand hygiene and infection control during wound treatment and medication administration.
Report Facts
Residents reviewed: 33
Residents reviewed: 36
Medication carts inspected: 7
Medication administration observations: 3
Residents affected: 1
Residents affected: 1
Residents affected: 2
Residents affected: 21
Residents affected: 1
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) | Observed failing to provide resident privacy during wound treatment and confirmed privacy breach | |
| Registered Nurse Unit Manager (RNUM) | Assisted LPN during wound treatment and discussed privacy concerns | |
| Director of Nursing (DON) | Discussed privacy concerns, medication administration issues, and physician order deficiencies with surveyor | |
| Licensed Nursing Home Administrator (LNHA) | Discussed medication monitoring and physician order deficiencies with surveyor | |
| Unit Manager/Registered Nurse (UM/RN) | Responded to inquiries about medication monitoring and dialysis medication scheduling | |
| Consultant Pharmacist (CP) | Provided monthly medication review and recommendations for medication scheduling | |
| Food Service Director (FSD) | Observed food service worker hand hygiene and kitchen sanitation issues | |
| Food Service Worker (FSW) | Observed washing hands and wiping sink basin improperly | |
| Licensed Practical Nurse (LPN #1) | Observed breaching infection control during wound treatment | |
| Licensed Practical Nurse (LPN #2) | Observed breaching hand hygiene during medication pass |
Inspection Report
Annual Inspection
Census: 169
Deficiencies: 10
Date: Nov 5, 2021
Visit Reason
Annual standard survey conducted to assess compliance with federal and state regulations for long term care facilities.
Findings
The facility was found not in substantial compliance with multiple regulatory requirements including resident privacy, professional standards of care, medication monitoring, physician order documentation, drug regimen review, medication storage, food safety, infection prevention and control, staffing ratios, and life safety code compliance related to HVAC systems.
Deficiencies (10)
Failed to provide visual privacy for a resident during treatment.
Failed to follow a physician's order to monitor the blood level of a drug for a resident.
Failed to provide resident assessment and monitoring upon return from dialysis and failed to schedule medications according to dialysis days.
Failed to ensure physicians signed and dated monthly physician orders for multiple residents.
Failed to act upon consultant pharmacist's recommendations regarding medication regimen review.
Failed to store unopened medications properly in medication carts.
Failed to store and maintain food and kitchen equipment in a sanitary manner, including soiled oven knobs, stove tops, and dented cans.
Failed to follow infection prevention and control practices including hand hygiene during food preparation, treatment observations, and medication pass.
Failed to maintain required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey.
Failed to ensure proper functioning of bathroom exhaust ventilation systems in 2 of 11 resident bathrooms.
Report Facts
Census: 169
Sample Size: 38
Deficiency Count: 21
Staffing Ratio: 165
Staffing Ratio: 170
Staffing Ratio: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in infection control breach during treatment observation. |
| LPN #2 | Licensed Practical Nurse | Observed failing to wash hands properly during medication pass. |
| Director of Nursing | Director of Nursing | Involved in discussions and corrective actions for multiple deficiencies. |
| Administrator | Administrator | Involved in discussions and corrective actions for multiple deficiencies. |
| Maintenance Director | Maintenance Director | Involved in inspection and corrective action for ventilation system deficiencies. |
| Food Service Director | Food Service Director | Observed food safety and hand hygiene deficiencies. |
Inspection Report
Routine
Census: 147
Deficiencies: 0
Date: Jan 27, 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.
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: 8
Viewing
Loading inspection reports...
