Cedar Crest/Mountainview Gardens

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to keep the call bell soft pad within residents' reach. This deficient practice was identified for 2 of 22 residents reviewed for accommodation of needs (Resident #57 and #112), and was evidenced by the following: 1. On 01/22/2026 at 11:40 AM, the surveyor observed Resident #57 in their room, with eyes closed, seated in a wheelchair in front of the sink. The surveyor observed that the call bell soft -touch pad (a device used to summon the staff for assistance) was on the bedside table, not within the resident's reach. On 1/23/26 at 9:35 AM, the surveyor observed Resident #57 in their room, with eyes closed, seated in a wheelchair in front of the sink. The surveyor observed that the call bell soft -touch pad was on the bedside table, not within Resident #57's reach. The surveyor reviewed the medical record for Resident #57. A review of the admission Record reflected that the resident was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and review of other facility documentation, it was determined that the facility failed to follow appropriate hand hygiene practices during dining observations in 1 of 3 dining rooms (2nd floor) and for 2 of 3 staff members (Certified Nursing Assistant (CNA)) and Registered Nurse (RN) during meal service. This deficient practice was evidenced by the following: According to the CDC Clinical Safety: Hand Hygiene for Healthcare Workers dated 2/27/24, Healthcare personnel should use an alcohol-based hand rub (ABHR) or wash with soap and water for the following clinical indications:Immediately before touching a patient .After touching a patient or the patient's immediate environmentAfter contact with blood, body fluids, or contaminated surfacesImmediately after glove removal. On 01/23/2026 at 9:45 AM, the surveyor observed meal service in the 2nd-floor dining room and observed the following: On 1/23/26 at 9:45 AM, the RN entered the dining room and assisted Resident #5 with their meal. The surveyor observed that the RN fed the resident and then, with no…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Complaint #: NJ184124 Based on interviews, record review, and review of other pertinent facility documentation on [DATE] and [DATE], it was determined that the facility failed to follow a resident's (Resident #2) wishes for a Do Not Resuscitate (DNR) status who had a signed Physician's Order (PO) and a Practitioner Orders for Life- Sustainable Treatment (POLST) in their chart when the resident experienced a cardiac arrest on [DATE]. This deficient practice was identified for one resident (Resident #2), and is evidenced by the following: According to the admission Record, Resident #2 was admitted to the facility with diagnoses which included but were not limited to: Dementia (memory loss), Hypertension (a condition in which blood in the artery wall is too high) and Muscle Weakness. A review of the admission Minimum Data Set, an assessment tool used to facilitate the management of care dated [DATE], reflected that the resident had a Brief Interview for Mental Status score of 10 out of 15, indicating that the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Complaint #: NJ184124 Based on interviews, record review, and review of other pertinent facility documentation on 03/11/2025 and 03/12/2025, it was determined that the facility failed to completely fill out a Medical Record (MR) which contained the New Jersey Universal Transfer Form (NJUTF) for a resident (Resident #2) who was sent out to the Hospital. This deficient practice was identified for one resident (Resident #2), and was evidenced by the following: According to the admission Record, Resident #2 was admitted to the facility with diagnoses which included but were not limited to: Dementia (memory loss), Hypertension (a condition in which blood in the artery wall is too high) and Muscle Weakness. A review of the Resident #2's Progress Notes (PN) revealed that on 02/21/2025 at 4:01 P.M., the Registered Nurse (RN) documented that Resident #2 needed to be sent out to the emergency room (ER) for tachycardia, nauseous, and complain of weakness. A review of Resident #2's MR revealed the NJUTF for the 02/21/2025 transfer to the ER was not filled out completely. During an interview…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and review of facility policies, it was determined that the facility failed to maintain proper kitchen sanitation practices in a manner to prevent food borne illness. This deficient practice was observed and evidenced by the following: On 9/4/24 at 9:21 AM, the surveyor in the presence of the Campus Executive Chef (CEC) observed the following during the kitchen tour: 1. On the preparatory table, the surveyor observed the can opener with a caked on black colored debris. The CEC stated, they were unsure when the can opener was cleaned last, but the can opener would be cleaned immediately. 2. In the cooking area of the kitchen, the surveyor observed the standing dual oven with a sticky yellowish substance and dust like particles on top of the oven. CEC not sure when the oven was last cleaned was last cleaned. 3. The deep fryer was observed with multiple food crumbs around the inside of the fryer. Per Chef #1 the fryer was not used today, unable to explain why food crumbs were present and not cleaned last night after use. 4. The standing combination oven…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review, and review of facility polices it was determined that the facility failed to: a.) carry out medication orders for a hospice resident and b.) clarify an oxygen order. This deficient practice was identified for 2 of 12 Residents (Resident #67 and #3) reviewed. The deficient practices were evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or restorative of life and wellbeing, and executing medical regimens as prescribed by a licensed or otherwise legally authorized physician or dentist. Reference: New Jersey Statutes Annotated, Title 45, Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on the interview and record review, it was determined that the facility failed to code the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care of all residents, accurately for 1 of 25 residents reviewed (Resident # 113). The deficient practice was evidenced by the following: The surveyor reviewed Resident # 113's records. The resident reviewed 1/23/24, was discharged from the facility and according to the Discharge Return Anticipated MDS, an assessment tool used to facilitate the management of care, dated 6/27/24, the Type of Discharge was indicated as unplanned. A review of Resident # 113's progress notes dated 6/18/24, revealed the resident had a planned discharged to an Assisted Living (AL) facility. On 9/9/24 at 12:20 PM, the surveyor interviewed the MDS Coordinator, who stated that the MDS under section A Typer of Discharge for Resident # 113 should have indicated that the resident's discharge was planned. During an interview on 9/9/24 at 1:20 PM, the surveyor brought the above concerns to the attention of the Director of Nursing and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, review of medical records, and other pertinent facility documentation, it was determined that the facility failed to a.) follow appropriate hand hygiene and appropriate use of personal protective equipment (PPE) for 1 of 4 staff observed on 1 of 4 Nursing Units. This deficient practice was evidenced by the following: According to the Center for Disease Control and Prevention (CDC) Clinical Safety: Hand Hygiene for Healthcare Workers dated 02/27/24 revealed: Healthcare personnel should use an alcohol-based hand rub (ABHR) or wash with soap and water for the following clinical indications: Immediately before touching a patient . Before moving from work on a soiled body site to a clean body site on the same patient . After touching a patient or the patient's immediate environment After contact with blood, body fluids, or contaminated surfaces Immediately after glove removal. On 9/5/24 at 11:12 AM, the surveyor observed the Certified Nursing Assistant (CNA) on the Terrace Unit,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, it was determined that the facility failed to notify the resident or the resident's representative in writing for a facility-initiated transfer to the hospital. This deficient practice was identified for 2 of 2 residents (Resident #103 and #111) reviewed for hospitalization discharge. The deficient practice was evidenced by the following: 1. On 5/17/23 at 1:31 PM, the surveyor reviewed the hybrid medical records (paper and electronic) of Resident #103. The medical record revealed that the resident was transferred to the hospital on 3/2/23. According to the Discharge Minimum Data Set (MDS), an assessment tool used to facilitate the management of care dated 3/2/23, reflected that Resident #103 was discharged to the hospital with a return anticipated to the facility. On 5/23/23 at 1:15 PM, the surveyor discussed the transfer of Resident #103 to the hospital with the Licensed Nursing Home Administrator (LNHA) regarding written notification of discharge. The Administrator stated that no written notification was sent to the family or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, it was determined that the facility failed to complete a quarterly Minimum Data Set (MDS), an assessment tool, for 1 of 26 residents, Resident # 17, system selected for MDS over 120 days and was evidenced by the following: Reference: The Centers for Medicare and Medicaid (CMS) Resident Assessment Instrument (RAI) Version 3.0 Manual classified the Observation (Look Back) Period as the time period over which the resident's condition or status was to be captured by the MDS. The Assessment Reference Date (ARD) referred to the last day of the observation (or look back) period that the assessment covered for the resident. The Quarterly assessment was considered timely if 1). The Assessment Reference Date (ARD) of the Quarterly MDS was within 92 days after the ARD of the previous MDS and; 2). the completion date was no later than 14 days after the ARD. On 5/24/23 at 9:30 AM, the surveyor reviewed the medical records of Resident #17. A review of the MDS for Resident #17 revealed that a Quarterly MDS with an ARD of 1/9/23 was completed. The next…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and review of other facility documentation, it was determined that the facility failed to develop a comprehensive person-centered care plan for a resident under Hospice care (care for a terminally ill person who's expected to have six months or less to live). This deficient practice was identified for 2 of 4 residents reviewed for Hospice comprehensive person-centered care plans, Resident #21 and Resident #35 and was evidenced by the following: 1. On 5/18/23 at 12:10 PM, the surveyor observed a STOP sign posted right outside Resident #21's room door. There was also signage indicating please keep door closed at all times thank you. On 5/18/23 at 1:53 PM, the surveyor reviewed the hybrid medical records for Resident #21. According to the resident's admission record, the resident was admitted to the facility with diagnoses which included but were not limited to, Cerebral Infarction, Chronic Kidney Disease, and active COVID 19 respiratory infection. A review of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.