Crest Haven Nursing And Rehabilitation Center

F 0656 Level of Harm - Minimal harm or potential for actual harm

included under Policy Interpretation: 7.c) The care planning process will incorporate the resident's personal and cultural preferences in developing the goals of care. 8.c.) Describe services that would otherwise be provided for the above, but are not provided due to the resident exercising his or her rights, including the right to refuse treatment. N.J.A.C. 8:39 - 11.2 (d)

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/30/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Crest Haven Nursing and Rehabilitation Center

4 Moore Road Cape May Court House, NJ 08210

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, interview, record review, and review of facility documents, it was determined that the facility failed to revise an individual Comprehensive Care Plan for a resident with a change in code status. This deficient practice was identified for 1 of 3 residents (Resident #2) reviewed and was evidenced by the following:On [DATE REDACTED] at 10:05 AM, the surveyor observed Resident #2 in the activities room lying in a recliner. The resident interview was not possible due to a diagnosis of dementia (memory loss). On [DATE REDACTED] at 12:21 AM, the surveyor reviewed the medical record for Resident #2. A review of the admission Record (an admission summary) reflected Resident #2 was admitted to the facility with medical diagnoses that included but were not limited to; dementia, anxiety disorder, and protein-calorie malnutrition (inadequate intake of protein and calories). A review of the comprehensive Minimum Data Set (MDS), an assessment tool used to facilitate the management of the Resident's care dated [DATE REDACTED], indicated that Resident #2 had short and long-term memory deficits. The Resident was severely impaired for decision making and required maximum assistance for most activities of daily living (ADLs). A review of the resident's Order Summary Report (OSR), dated [DATE REDACTED], included the following physician's orders (PO) to consult hospice for evaluation and treatment, do not resuscitate (DNR), and do not intubate (DNI). A review of the Individualized Comprehensive Care Plan (ICCP) included a focus area dated [DATE REDACTED], for an Advanced Directive of Full Code. Interventions included: code status will be reviewed quarterly with a resident and/or responsible party, cardiopulmonary resuscitation (CPR), [a lifesaving technique to restart a person's heartbeat and breathing], will be performed as ordered, follow facility protocol for identification of code status, keep the family informed of change in condition, and provide emotional support as needed. The ICP was not updated to reflect the physician's order regarding the change in the Resident's code status from Full code to DNR and DNI. A review of the Progress Notes (PN) included a nurse's note, dated [DATE REDACTED] at 10:26 PM, which included that Resident #2 was admitted into hospice with new orders. On [DATE REDACTED] at 12:05 PM, the surveyor interviewed the Certified Nursing Assistant (CNA), who stated that the Resident had recently change to hospice care and confirmed that the hospice staff provided care in the mornings. On [DATE REDACTED] at 12:27 PM, the surveyor interviewed the Licensed Practical Nurse (LPN), who confirmed that a change of code status for hospice care required updating the care plan to reflect changes so that staff can provide the appropriate care. On [DATE REDACTED] at 12:44 PM, the surveyor interviewed the first floor Unit Manager (UM), an LPN, who explained that for hospice residents, a Physician Orders for Life Sustaining Treatment (POLST) {medical orders for preferences regarding life-sustaining treatment}, is completed with the resident and family and signed by the doctor. The UM stated that for a change of code status the Resident's care plan must be updated immediately to ensure that the correct care is administered should an emergency occur. The UM further explained that she was responsible for updating and ensuring the accuracy of ICCP when a resident code status changes. However, Resident #2's care plan was not updated. On [DATE REDACTED] at 12:52 PM, the surveyor interviewed the Director of Nursing, who confirmed that when an order is received for hospice and a change in code status, the care plan is immediately updated. However, Resident #2's, care plan did not reflect a change of code status as ordered on the OSR. The facility policy Care Plans, Comprehensive, Person-Centered, reviewed/revised date 8/2025, indicated that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. NJAC 8:39-27.1(a)

Event ID:

Facility ID:

If continuation sheet