Crest Pointe Rehabilitation And Healthcare Center

F-F600

1. On 6/3/24 at 10:58 AM, Resident #79 reported to the surveyor that Certified Nursing Aide (CNA #1) had made sexual comments towards them, and they refused male aides. The resident stated CNA #1 told them to bend over and they replied, no thank you and CNA #1 stated you will like it. The resident continued on another the day; CNA #1 stated Don't take this the wrong way but your hair looks sexy that way. The resident stated that the non-certified Nursing Aide (NA) and Rehabilitation Director (Rehab Director) were both present, and the comments as well as CNA #1 made them uncomfortable. The resident stated he/she complained to administration about it, but the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), or Assistant Director of Nursing (ADON) had not spoken to them about the incident; he/she stated they were informed CNA #1 was spoken to.

The surveyor reviewed the medical record for Resident #79.

A review of the Admission Record face sheet (an admission summary) reflected the resident was admitted to

the facility with diagnoses which included post-traumatic stress disorder (PTSD) and major depressive disorder.

A review of the most recent quarterly Minimum Data Set (MDS), an assessment tool dated 2/29/24, the resident had a brief interview for mental status (BIMS) score of 15 out of 15; which indicated a fully intact cognition.

On 6/4/24 at 9:04 AM, the surveyor requested all grievances and investigations for Resident #79.

A review of a grievance dated reported 5/16/24 and resolved 5/17/24 by the Social Worker (SW), indicated that Resident #79 reported [he/she] had a poor service interaction with Aid on the unit. Summary of investigation included SW did follow-up and [he/she] said [he/she] used profanity to him the CNA (#1) as

they were joking around and then he walked away. SW asked if [he/she] would prefer not to have interaction with him [CNA #1] and [he/she] was satisfied with that. Unit Manager made aware; Aide is not assigned to resident and will have no contact. The grievance included no statements form the resident, witnesses, CNA #1, any residents CNA #1 may have come in contact, or education.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 34 315135 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315135 B. Wing 06/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Crest Pointe Rehabilitation and Healthcare Center 1515 Hulse Road PT Pleasant, NJ 08742

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 0610 On 6/5/24 at 8:26 AM, the surveyor interviewed the NA who stated there was an incident between Resident #79 and CNA #1 about a month ago where she had gotten the resident ready for physical therapy and they Level of Harm - Minimal harm or were waiting in the dining room with CNA #1. The NA stated that CNA #1 and herself were joking with the potential for actual harm resident, and she was unsure who initiated the interaction, but the resident stated to CNA #1 bite me and CNA #1 stated bend over and I had left because the Rehab Director came in. The NA reported that the Residents Affected - Some Rehab Director told her that after that interaction, the resident used profanity in a non-joking way, and CNA #1 stated are you sure about that and the resident responded ew. The NA stated she did not report the incident at first because she thought everyone was joking, but when the resident reported to her that it made [him/her] feel a certain way, she asked if they wanted to speak to the SW to report it, and the resident stated yes. The NA reported now they are just investigating it.

On 6/5/24 at 9:00 AM, the surveyor asked the DON if CNA #1 was working today, and the DON stated CNA #1 was suspended pending investigation for an allegation of abuse from a resident as of 6/3/24 (first day of survey).

On 6/5/24 at 9:08 AM, the surveyor interviewed the Rehab Director who stated about a month ago, the resident was waiting for therapy in the dining room with the NA and CNA #1. The Rehab Director informed

the resident therapy was ready, and in a joking way CNA #1 stated ya go do something and the resident laughed and stated, bite me and CNA #1 said bend over and the resident responded with profanity. The Rehab Director stated while on their way to therapy, the resident saw the SW and immediately reported the incident to them.

On 6/5/24 at 10:00 AM, the surveyor conducted a telephone interview with CNA #1 who stated there was an incident with the resident two or three weeks ago but cannot recall the details, and then I was told there was another altercation where I told the resident their hair looked nice, but they took it the wrong way. CNA #1 stated he spoke with the SW about the incident maybe two or three weeks ago, but was never asked for a statement or instructed not to interact with the resident. CNA #1 stated after the incident, he took it upon himself to not interact with the resident.

On 6/5/24 at 10:09 AM, the surveyor re-interviewed Resident #79 who stated after speaking to the surveyor about their concern with CNA #1 on Monday, the LNHA and DON came to speak to them about the incident.

The resident confirmed they never requested to speak to them that day, or informed any staff their concern that day.

On 6/5/24 at 10:28 AM, the surveyor interviewed the SW who stated she started the grievance process, but

the LNHA was the Grievance Officer who completed the grievance. The SW stated Resident #79 had an interaction with CNA #1, and she spoke to CNA #1, but she did not obtain a statement. The SW continued

the nursing department would obtain statements from the nursing staff, but she could not speak to why one was not obtained. The SW stated that the LNHA had access to this grievance.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 34 315135 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315135 B. Wing 06/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Crest Pointe Rehabilitation and Healthcare Center 1515 Hulse Road PT Pleasant, NJ 08742

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 0610 On 6/5/24 at 10:39 AM, the surveyor interviewed the DON (as of 5/29/24) who stated the facility investigated all allegations of abuse which included asking the resident what happened and obtaining a statement; obtain Level of Harm - Minimal harm or statements from staff and witnesses; suspend staff the allegation was made against pending investigation. potential for actual harm The DON stated she was informed by the LNHA on Monday (6/3/24) that they needed to speak to Resident #79, but was given no additional information. The DON stated the resident reported to them the SW was Residents Affected - Some aware of the situation, and the DON confirmed the allegation should have been investigated at that time; statements should have been gathered; and CNA #1 should have been suspended at the time pending investigation.

On 6/5/24 at 10:55 AM, the surveyor interviewed the LNHA who confirmed he was the Grievance Officer with

the assistance of the SW. The LNHA stated sometimes he gathered statements or sometimes the SW did, but the facility investigated all grievances. The LNHA stated the facility obtained statements, but they were not always written. The LNHA stated he typically reviewed all grievances to ensure everything was taken care of, and usually grievances were reviewed weekly at a meeting, but sooner if needed. The LNHA stated

he spoke to the SW about this incident, and the SW spoke to the parties involved at the time.

At that time, the surveyor reviewed the grievance dated 5/16/24, with the LNHA and asked where on the grievance did it indicate what poor experience meant, and the LNHA confirmed it did not, and should be looked at to rule out abuse. The LNHA stated he did remember a conversation with the SW, but it was not documented, and there could have been a more written clarification or explanation of poor experience. The surveyor asked why the LNHA spoke to Resident #79 on Monday regarding this concern, and the LNHA stated someone had mentioned in a meeting that day that he should speak to him/her. The surveyor asked

the LNHA what the facility's policy indicated for investigating abuse, and the LNHA stated he was unsure.

2. On 6/7/24 at 9:09 AM, the Regional LNHA in the presence of the LNHA, and DON informed the survey team that upon in-servicing staff on abuse, it was brought to their attention by the Business Office Manager (BOM) that the facility should speak to Resident #60 regarding an incident that should be investigated. The BOM stated the Resident's Representative (RR) reported to them the incident involving Resident #60; that

after being discharged from Medicaid services, the Unit Manager/Licensed Practical Nurse (UM/LPN) informed a CNA (unknown) not to help a resident pick up a sock. The incident occurred maybe a week ago, but no one had a definite date. The Regional LNHA continued the BOM indicated in her written statement that the LNHA was aware of the concern.

At that time, the surveyor asked the LNHA if he was made aware, the LNHA stated he was made aware that Resident #60 had concerns with his/her activities of daily living (ADL) care and wanted additional help with ADLs, so he asked the UM/LPN to speak to the resident to see if additional help was needed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 34 315135 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315135 B. Wing 06/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Crest Pointe Rehabilitation and Healthcare Center 1515 Hulse Road PT Pleasant, NJ 08742

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 0610 On 6/7/24 at 9:25 AM, the surveyor interviewed Resident #60 who stated he/she needed help with ADLs such as putting his/her sock on since they cannot reach their feet, and yesterday the facility provided them Level of Harm - Minimal harm or with this assistive device to put my socks on that cannot use. The resident continued the facility just wanted potential for actual harm to supplement with equipment when I asked for help; it makes me feel like they care more about not taking care of me than helping me. The resident continued that they felt bad asking staff for help and ringing the call Residents Affected - Some bell because people abuse the call bell and take up too much of the staff's time, so he/she tried to be more independent which resulted in increased physical pain, so the facility increased their pain medication. The resident stated since he/she did not use the call bell and tried to do tasks on their own, he/she was discontinued from Medicaid, and after that, when I asked for help, the UM/LPN came to my room angry and scolded me for asking for help and was really mad when I explained my side. The one day CNA #1 helped me, and the UM/LPN was really mad and told me I knew I was not supposed to ask for help. Then I went out of my room and the UM/LPN at the nurse's station in front of people, yelled at me saying I lied to her and she was committing perjury if she allowed anyone to help me. The resident stated this made him/her embarrassed and afraid, and fearful of her acting on her anger which caused me emotional harm, and fear of what am I going to do; no one is going to help. The resident stated the BOM was aware of this, and the UM/LPN would walk passed his/her room staring which made him/her uncomfortable because the look was not welcoming to want to help and she told me I did not need help. The resident stated he/she was not good with dates, but to call his/her RR who was aware of the whole situation and knew the dates.

On 6/7/24 at 9:50 AM, the surveyor conducted a telephone interview with CNA #1 who stated the UM/LPN informed him if the resident needed help, to help them, but the resident did not need much help. CNA #1 recalled an incident at the nurse's station, but the resident was yelling at the UM/LPN and the UM/LPN was not yelling but was sternly telling the resident what was to be done.

On 6/7/24 at 10:29 AM, the surveyor interviewed the BOM who stated sometime towards the end of May

after the resident was denied from Medicaid, was informed the Rehab Director, UM/LPN, and a CNA (unknown) was very rude to [him/her] because [he/she] started asking for help. Upon hearing that, the BOM reported that she immediately informed the LNHA that the resident reported the Rehab Director, UM/LPN, and a CNA were very rude because [he/she] didn't need help, but after [he/she] was denied Medicaid [he/she] started asking for help and [he/she] said that staff feel [he/she] is faking it. The BOM confirmed she had followed-up with the LNHA after a meeting, and he reported that he had already spoken to staff and not

the resident about it. The BOM stated yesterday after she was in-serviced on abuse, she reminded the LNHA of the incident in front of the Regional LNHA, DON, and Regional Nurse. The BOM stated when she first informed the LNHA, she was never asked to provide a statement.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 34 315135 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315135 B. Wing 06/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Crest Pointe Rehabilitation and Healthcare Center 1515 Hulse Road PT Pleasant, NJ 08742

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 0610 On 6/7/24 at 11:00 AM, the surveyor interviewed the RR via telephone who stated the incident occurred two weeks ago yesterday (6/23/24), after the RR encouraged the resident to start asking for help from facility Level of Harm - Minimal harm or staff. The RR stated the resident was removed from assisted living because he/she could no longer walk and potential for actual harm required twenty-four-hour nursing assistance. The RR stated the resident began asking for help, and the UM/LPN went to the resident and started yelling at him/her and the resident called and informed the RR. The Residents Affected - Some RR stated the resident was now calling him/her multiple times a day; that their anxiety had increased. The RR reported that the UM/LPN brought the resident in front of all the nurses and told them not to help the resident. The RR stated when he/she was made aware, they spoke with the Director of Rehab who would not let them speak and spoke over them. The RR stated he/she then spoke to the UM/LPN to explain the resident's medical diagnosis of ankylosing spondylitis (AS) which was an autoimmune which caused systemic inflammation similar to MS (multiple sclerosis) in which the resident's spine was fusing and they could have good days or bad days. The RR stated the UM/LPN was aloof and what do you want me to do.

The RR stated he/she reported this to the BOM who reported it to the SW, and the SW called back a few days later and the RR reported that the nurses will not help the resident. The RR reported the SW informed them that the facility was aware, and they spoke with staff. The RR reported staff was questioning why the resident needed help which increased the resident's anxiety, as well as the UM/LPN was walking by the resident's room not speaking to them causing more anxiety, and the UM/LPN was telling the resident they were an alcoholic and will be kicked out (recovering alcoholic for years) and they were committing fraud if

they helped.

Review of the BOM's undated statement included during my meeting with [Resident #60], [he/she] told me that the Director of Rehab, the nurse (UM/LPN) and the CNAs in the unit were rude to [him/her]. [He/she] was told that they would not help, and they would not document any assistance they were providing [him/her]. I reported this to the LNHA right away, asked him if he could talk to the Rehab Director and staff on

the unit which he told me he already did. On 6/3/24, I received a call from the RR with regards to the Medicaid denial, and he/she voiced their concern of how staff treated the resident, and he/she wants to call

the Ombudsman's office. After I spoke to the RR, I spoke to the SW to give the RR a call, and she did.

The surveyor reviewed the medical record for Resident #60.

A review of the Admission Record face sheet indicated the resident was admitted to the facility with diagnoses which included muscle wasting and atrophy; generalized muscle weakness; depression, and anxiety.

A review of a Social Services Note dated 6/3/24, included SW spent time with resident and gave name of an independent living facility. Resident asked me to call RR; and the RR stated they do not need assistance finding a location as they will appeal the denial for long term care Medicaid. The note did not include the resident or RR's concern about staff.

On 6/10/24 at 9:15 AM, the surveyor interviewed the Regional LNHA who was the acting facility administrator, in the presence of the DON who stated the facility should investigate all concerns. The Regional LNHA stated an investigation included interviewing all the parties involved and getting statements; written or verbal, and verbal statements taken over the phone should be documented. Statements generally were a seventy-two hour lookback if the incident was unwitnessed, but the purpose of the investigation was to determine what actually occurred.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 34 315135 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315135 B. Wing 06/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Crest Pointe Rehabilitation and Healthcare Center 1515 Hulse Road PT Pleasant, NJ 08742

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 0610 A review of the facility's undated Abuse Prevention Program policy included the administration will implement

the following protocols: 1. protect our residents from abuse by anyone including, but not necessarily limited Level of Harm - Minimal harm or to: facility staff .investigate and report any allegation of abuse within timeframe as required by federal potential for actual harm requirements; protect residents during abuse investigations .

Residents Affected - Some A review of the facility's undated Grievances/Complaints, Recording and Investigating policy included the administrator has been assigned the responsibility of investigating grievances and complaints to the grievance officer; upon reviewing grievance and complaint report, the grievance officer will begin an investigation into the allegation .the investigation and report will include, as applicable: the date and time of alleged incident; circumstances surrounding the alleged incident; the location of the alleged incident; the names of any witnesses and their accounts; the resident's alleged account; accounts of any other individuals involved .the grievance officer will coordinate actions with the appropriate state and federal agencies, depending on the nature of the allegations .

A review of the facility's Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating policy dated revised September 2022, included upon receiving any allegation of abuse [ .] the administrator is responsible for determining what actions (if any) are needed for the protection of the residents; all allegations are thoroughly investigated. The administrator initiates investigation .the administrator provides supporting documents and evidence related to alleged incident to the individual in charge of investigation .any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete; the individual conducting the investigation at minimum: a. reviews the documentation and evidence; .d. interviews the person (s) reporting the incident; e. interviews any witnesses to the incident; interviews the resident [ .]; j. interviews other residents to whom the accused employee provides care or services; .l. documents the investigation completely and thoroughly. The following guidelines are used when conducting interviews: .witness statements are obtained in writing, signed and dated .

NJAC 8:39-4.1(a)5

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 34 315135 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315135 B. Wing 06/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Crest Pointe Rehabilitation and Healthcare Center 1515 Hulse Road PT Pleasant, NJ 08742

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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 27193 potential for actual harm Based on observation, interview and review of facility documentation, it was determined that the facility failed Residents Affected - Some to: a.) ensure that staff were trained to properly assess and document care of the hemodialysis access sites which includes the auscultation/palpation of the atrio-ventricular (AV) fistula (a surgical connection connection between an artery and a vein) for bruit (an abnormal sound generated by turbulent arterial blood flow) and thrill (a palpable sensation of blood flow) to assure adequate blood flow and to monitor the hemodialysis access site for bleeding, signs of infection and pain. This deficient practice was identified for 2 of 2 residents reviewed for hemodialysis treatment(Resident #4 and #50) and was evidenced by the following:

On 6/6/24 at 10:55 AM, the surveyor observed Resident #50 seated in a wheelchair at the bedside. Upon inquiry, Resident #50 stated that they had kidney failure and was receiving hemodialysis (the filtration of waste when the kidneys are no longer able to do so). Resident #50 showed the left arm to the surveyor and stated, this is the site. Resident #50 added that he/she went to hemodialysis every Monday, Wednesday and Friday. The surveyor then inquired how often the nurses checked the site, Resident #50 indicated the nurses do not checked the site here; the staff at the dialysis center checked the hemodialysis site. The surveyor observed an AV shunt on Resident #50's left arm. The surveyor observed two bandages on the left arm.

On 6/6/24 at 12:30 PM, the surveyor reviewed the Admission Record face sheet (an admission summary) which reflected that Resident #50 was admitted to the facility with diagnoses which included but were not limited to; anemia in chronic kidney disease, end stage renal disease (medical condition in which a person's kidneys cease functioning on a permanent basis leading to the need for a regular course of long-term dialysis or a kidney transplant to maintain life), diabetes mellitus with diabetic neuropathy (chronic condition that affects the way the body processes blood sugar) neuropathy (a type of nerve damage that can occur with diabetes).

A review of the most recent comprehensive Minimum Data Set (MDS), an assessment tool dated 5/18/24, revealed that Resident #50 received a brief interview for mental status (BIMS) score of 15 out of 15; which indicated a fully intact cognition. A review of Section O. titled Special Treatments, Procedures, and Programs (J2) was checked which indicated that the resident received hemodialysis outside the facility.

A review of Resident #50's physician's orders sheet dated 5/12/24, indicated: check left peripheral access site, AV graft (shunt) site for bleeding, signs of infection, and the presence of bruit and thrill every shift.

A review of the corresponding Treatment Administration Record (TAR) dated 5/12/24 to 6/5/24, revealed that

the physician's order to check the left AV fistula (shunt) was documented as completed all three shifts by the nurses' initials.

A review of Resident #50's Dialysis Communication Records in the resident's dialysis communication binder dated 5/15/24 to 6/5/24, included to document the bruit and thrill. The bruit and thrill was no documented as checked on 5/22/24, 5/29/24, and 5/31/24. On 6/3/24, the nurse documented, No for bruit and thrill.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 34 315135 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315135 B. Wing 06/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Crest Pointe Rehabilitation and Healthcare Center 1515 Hulse Road PT Pleasant, NJ 08742

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 0698 On 6/6/24 at 10:55 AM, the surveyor interviewed the Licensed Practical Nurse (LPN #1) in charge of Resident #50's care who stated that Resident #50 had an AV fistula to the left arm. LPN#1 reviewed the Level of Harm - Minimal harm or order with the surveyor and confirmed that the order was for staff to check the site every shift. potential for actual harm At that time, the surveyor asked LPN #1 if he could check the site with the surveyor, and LPN#1 Residents Affected - Some accompanied the surveyor to the resident's room, and informed the resident of the procedure. LPN #1 used alcohol-based hand rub (ABHR) to sanitize his hands, then used the bell of the stethoscope to listen to the bruit, and then left the room. LPN #1 did not palpate for the thrill (thrill must be felt). In the presence of the nurse, Resident #50 informed the surveyor that the nurses never checked the site at the facility. LPN#1 did not make any comment regarding Resident #50's statement.

On 6/6/24 at 11:07 AM, during an interview with LPN #1, he revealed that he had been working at the facility over nine years, and stated that he possibly had received in-service on care of dialysis access site but he could not recall. The surveyor then asked LPN #1 how many dialysis residents were under his care, and he responded there was one other dialysis resident on the nursing unit.

On 6/10/24 at 9:00 AM, the Director of Nursing (DON), in the presence of the Regional Licensed Nursing Home Administrator (Regional LNHA) and survey team, acknowledged staff was only checking the resident for the bruit and not thrill.

2. On 6/6/24 at 11:12 AM, the surveyor observed LPN #2 in the hallway who confirmed that Resident #4 was

on her assignment. LPN #2 informed the surveyor that she had to check the AV fistula prior to dialysis on Monday, Wednesday, and Friday. The surveyor asked the nurse to demonstrate how to check the dialysis access site.

On 6/6/24 at 11:15 AM, LPN #2 accompanied the surveyor in the resident's room to demonstrated how she checked the dialysis access site. LPN #2 used the bell of the stethoscope to listen to the bruit, LPN #2 did not palpate for the thrill. Upon inquiry, LPN #2 informed the surveyor that she used the stethoscope to listen for both the bruit and the thrill, and she was not aware that she must use the palm of her fingers to palpate for the thrill. The surveyor then asked LPN #2 if she recalled any in-service education received regarding the care of the hemodialysis access site, she stated, I cannot recall.

The surveyor reviewed the medical record for Resident #4.

A review of the Admission Record face sheet that Resident #4 was admitted to the facility with diagnoses which included, but were not limited to; end stage renal disease, anorexia nervosa and adjustment disorder.

Resident #4 was scheduled to receive dialysis treatment on Monday, Wednesday and Friday.

A review of the most recent quarterly MDS dated [DATE REDACTED], reflected that the resident had a BIMS score of 13 out of 15, which indicated a fully intact cognition.

A review of the Physician Order Sheet (POS) included a physician's order dated 5/15/2020; to check the AV fistula for thrill and bruit every shift. The order was transcribed on the TAR and initialed by the nurses on all three shifts as being checked as ordered.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 34 315135 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315135 B. Wing 06/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Crest Pointe Rehabilitation and Healthcare Center 1515 Hulse Road PT Pleasant, NJ 08742

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 0698 On 6/10/24 at 9:00 AM, the DON in the presence of the Regional LNHA and survey team acknowledged that staff was checking the resident's dialysis access site for bruit, but not the thrill. Level of Harm - Minimal harm or potential for actual harm A review of the facility's Hemodialysis Catheters- Access and Care of policy dated last revised 2/2023, included the purpose: hemodialysis catheters will only be accessed by medical staff who have received Residents Affected - Some training and demonstrated clinical competency regarding use of this catheter . Care of AV Fistula and AV Grafts procedure .4(h) check patency of the site at regular intervals. Palpate the site to feel the thrill, or use a stethoscope to hear the whoosh or bruit of blood through the access .

NJAC 8:39-27.1(a)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 34 315135 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315135 B. Wing 06/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Crest Pointe Rehabilitation and Healthcare Center 1515 Hulse Road PT Pleasant, NJ 08742

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 0728 Ensure that nurse aides who have worked more than 4 months, are trained and competent; and nurse aides who have worked less than 4 months are enrolled in appropriate training. Level of Harm - Minimal harm or potential for actual harm 38080

Residents Affected - Many Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure a system was in place that non-certified Nursing Aides (NA) did not continue to work in the facility as a NA past 120 days. This deficient practice was identified for 5 of 5 NAs who worked at the facility for more than 120 days reviewed for sufficient staffing (NA #1, #2, #3, #4, and #5), and was evidenced by the following:

During entrance conference on 6/3/24 at 9:17 AM, the surveyor asked the Licensed Nursing Home Administrator (LNHA) and Director of Nursing (DON) how the facility's nurse staffing was, and the LNHA stated it was good; that the facility did not need to use Agency staff. The surveyor asked if the facility used non-certified Nursing Aides (NA), and the LNHA stated they did; that past a certain amount of time (that he was unsure of) the NAs could have their own assignments. At that time, the surveyor requested a list of all NAs with their date of hire (DOH).

On 6/5/24 at 8:26 AM, the surveyor interviewed NA #1 who stated she had been at the facility since August of 2023 and just found out this week she could no longer have an assignment. NA #1 stated that the Human Resource (HR) person was new and was unaware of the timeframe NAs could work. NA #1 stated she enrolled in school immediately upon hire, and had her own resident assignment for care sometime in September. NA #1 stated she had her own assignment on Monday 6/3/24, and then was told she could not. NA #1 reported she completed school and passed the test, but she was waiting on the state background check and licensing.

On 6/5/24 at 11:43 AM, the LNHA provided the surveyor with the requested list of NAs with their DOH. The LNHA stated that the facility just identified that NAs needed to have their license within 120 days of working at the facility; he thought they had 120 days after they completed schooling. The surveyor asked the LNHA how many NAs the facility identified, and he stated one, NA #1.

The surveyor reviewed the list entitled Caring Partners which contained fourteen names. Out of the fourteen names, five had worked at the facility over 120 days as follows:

NA #1 DOH 8/2/23

NA #2 DOH 10/11/23

NA #3 DOH 12/20/23

NA #4 DOH 1/10/24

NA #5 DOH 1/10/24

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 34 315135 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315135 B. Wing 06/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Crest Pointe Rehabilitation and Healthcare Center 1515 Hulse Road PT Pleasant, NJ 08742

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 0728 On 6/6/24 at 12:18 PM, the surveyor interviewed NA #2, who stated he started school six months ago. NA#2 indicated that they just took the test and passed on Monday 6/3/24, and was now waiting on fingerprints and Level of Harm - Minimal harm or the background check from the state. When asked what took so long to take the test, NA #2 responded that potential for actual harm he wanted to make sure he knew the information. NA #2 confirmed he previously had his own resident care assignment, but today was told to answer call bells and not do care. Residents Affected - Many

The surveyor requested the nursing staff assignment sheets from October 2023 to present. A review of the sheet revealed the following:

NA #1 with a DOH 8/2/23 and 120 days as of 11/29/23, worked with a resident care assignment for 19 shifts

in December 2023; 12 shifts in January 2024; 17 shifts February 2024; 20 shifts March 2024; 17 shifts in April 2024; 20 shifts in May 2024; and three shifts in June 2024.

NA #2 with a DOH 10/11/23 and 120 days as of 2/7/24, worked with a resident care assignment for 20 shifts

in February 2024; 35 shifts in March 2024; 29 shifts in April 2024; 32 shifts May 2024; and four shifts in June 2024.

NA #3 with a DOH of 12/20/23 and 120 days as of 4/17/24, worked with a resident care assignment for 12 shifts in April 2024; and 27 shifts in May 2024.

NA #4 with a DOH of 1/10/24 and 120 days as of 5/8/24, worked with a resident care assignment for 21 shifts in May 2024; and two shifts in June 2024.

NA #5 with a DOH of 1/10/24 and 120 days as of 5/8/24, worked with a resident care assignment for 18 shifts in May 2024; and two shifts in June 2024.

On 6/7/24 at 8:39 AM, the surveyor interviewed the HR/Staffing Coordinator the presence of the LNHA and DON who stated she had been the Staffing Coordinator since December and the role of HR since 2021. The HR/Staffing Coordinator stated NAs were allowed to have their own resident care assignment after completing two weeks of school and shadowing a Certified Nursing Aide (CNA) for at least ten shifts. The HR/Staffing Coordinator acknowledged that a NA could not have a care assignment past 120 days in the building.

On 6/7/24 at 8:49 AM, the LNHA informed the surveyor that he was aware the facility used NAs and there was regulatory guidance regarding the usage, but he was unaware of the timing. The LNHA stated the Regional LNHA brought it to his attention on 6/3/24, and acknowledged it was important for him to be aware of the regulatory guidance because it was part of his job.

NJAC 8:39-25.2(g)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 34 315135 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315135 B. Wing 06/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Crest Pointe Rehabilitation and Healthcare Center 1515 Hulse Road PT Pleasant, NJ 08742

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 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Level of Harm - Minimal harm or potential for actual harm 39460

Residents Affected - Few Based on observation, interview, and review of pertinent facility documents, it was determined the facility failed to ensure an accurate ordering and receiving of narcotic medications on the required Federal narcotic acquisition forms (DEA 222 forms) were completed with sufficient detail to enable accurate reconciliation for 4 of 10 forms provided. The evidence was as follows:

On 6/4/24 at 1:00PM, the surveyor reviewed the facility provided DEA 222 forms which revealed on four of

the ten provided forms Part 5, had not been completed upon receipt of the medications from the provider pharmacy as instructed on the reverse of the ordering form. The forms were as follows:

Order form number: 231430013; 231430014; 231430015; and 231430016.

On 6/7/24 at 10:31 AM, the surveyor and Director of Nursing (DON) reviewed the provided DEA 222 forms.

The DON acknowledged she should have completed the Part 5 as instructed on the reverse of the DEA 222 form as required.

On 6/10/24 at 9:00 AM, the DON in the presence of the survey team and facility Administration stated she had been in-serviced on the proper way to complete the DEA 222 forms and again acknowledged the previously mentioned forms had not been completed correctly.

A review of the Instructions for DEA Form 222, under Part 5. Controlled Substance Receipt, 1. The purchaser fills out this section on its copy of the original order form. 2. Enter the number of packages received and date received for each line item .

A review of the facility's provided Medication Labeling and Storage policy with a revised date of February 2023 did not include information related to the completion of the DEA 222 forms.

NJAC 8:39-29.7(c)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 34 315135 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315135 B. Wing 06/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Crest Pointe Rehabilitation and Healthcare Center 1515 Hulse Road PT Pleasant, NJ 08742

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 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 38080

Residents Affected - Few Based on observation and interview, it was determined that the facility failed ensure potentially hazardous food was stored in a sanitary manner. The deficient practice was evidenced by the following:

On 6/3/24 at 10:22 AM, the surveyor toured the kitchen with the Food Service Director (FSD) and observed

the following:

In dry storage, five stacks of boxes containing food and beverage were stored directly on the floor which included a case of fruit cup salad; a case of pear juice; a case of coffee; a case of diced pears; two cases of cranberry juice; and a case of ketchup which were directly on floor. The FSD stated the food was just delivered and usually mats were placed on the floor first. The FSD acknowledged that food should not be stored directly on the floor.

At that time, the Regional FSD stated the boxes should have been placed on a mat or palate and not directly

on the floor.

On 6/7/24 at 12:33 PM, the surveyor informed the Regional Licensed Nursing Home Administrator (LNHA) who was acting facility administrator, in the presence of the Director of Nursing and survey team these findings.

A review of the facility's Food Receiving and Storage policy dated revised November 2022, included food in designated dry storage areas are kept at least six (6) inches off the floor (unless packaged for case lot handling, for example dollies, pallets, racks, and skids) and clear of sprinkler heads, sewage/waste disposal pipes and vents .

NJAC 8:39-17.2(g)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 34 315135 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315135 B. Wing 06/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Crest Pointe Rehabilitation and Healthcare Center 1515 Hulse Road PT Pleasant, NJ 08742

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 0835 Administer the facility in a manner that enables it to use its resources effectively and efficiently.

Level of Harm - Immediate 38080 jeopardy to resident health or safety Complaint # NJ 173248; 174364

Residents Affected - Some Based on interview, and review of pertinent facility documents, it was determined that the facility's Licensed Nursing Home Administrator (LNHA) failed to ensure staff, as well as himself, implemented the facility's abuse policies and procedures to ensure resident safety and well-being by a.) ensuring Resident #79 was free from verbal sexual abuse and b.) ensure Resident #60 was free from verbal abuse.

This deficient practice was identified for 2 of 3 residents reviewed for abuse (Resident #60 and #79).

Resident #79, who had diagnoses which included post-traumatic stress disorder (PTSD), anxiety, and depression reported to the Social Worker (SW) on 5/16/24, that Certified Nursing Aide (CNA #1) made sexual comments which included bend over; you will like it; and the resident's messy hair made them look sexy. This was witnessed by the nursing aide (NA), Rehabilitation Director (Rehab Director). Resident #79 reported that the comments by CNA #1 made them feel uncomfortable. The SW handled the incident as a grievance, which was reported as Resident #79 having poor service interaction with CNA #1 and was not investigated as an abuse allegation. The SW stated that the LNHA was the Grievance Officer and was aware of the incident. This situation resulted in the resident, who had PTSD from a past history of sexual abuse, to have increased anxiety with their PTSD exacerbated post incident with CNA #1 and resulted in an Immediate Jeopardy (IJ) situation.

A second resident, Resident #60, who had diagnoses which included depression, anxiety, ankylosing spondylitis (an autoimmune disease), who had a verbal altercation with the Unit Manger/Licensed Practical Nurse (UM/LPN) on 5/23/24, when the UM/LPN scolded and yelled at Resident # 60 for requesting assistance with activities of daily living (ADLs) from staff which caused the resident to become afraid and fearful of the nurse causing increased anxiety of who was going to help the resident. The incident was reported to the Business Office Manager (BOM) who immediately reported the incident to the LNHA, but did not start the investigation until 6/6/24, 2 weeks after the incident. The UM/LPN continued to work ten shifts with residents including Resident #60. This resulted in a second IJ situation.

The facility's failure to ensure all staff, including the LNHA, implemented their facility policies to guarantee all residents were free from abuse by not investigating the actions of CNA #1 after witnessed by staff, that the SW and LNHA were aware of; as well as the actions of the UM/LPN, which the BOM made the LNHA aware of, posed a serious and immediate threat for abuse that can cause serious physical and emotional harm or impairment, resulted in two IJ situations which the facility became aware of on 6/5/24 at 2:27 PM and 6/7/24 at 12:40 PM. Refer to F 600.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 34 315135 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315135 B. Wing 06/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Crest Pointe Rehabilitation and Healthcare Center 1515 Hulse Road PT Pleasant, NJ 08742

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 0835 This resulted in an IJ situation that began on 5/16/24 after CNA #1 verbally sexually abused Resident #79 and continued to work twelve additional shifts after staff was aware of the situation. The facility Level of Harm - Immediate Administration was notified of the IJ on 6/7/24 at 12:42 PM. The facility submitted an acceptable Removal jeopardy to resident health or Plan (RP) on 6/8/24 at 8:01 AM. The survey team verified the implementation of the Removal Plan during the safety continuation of the on-site survey on 6/10/24.

Residents Affected - Some The evidence was as follows:

A review of the Administrator's job description provided by the facility revealed the following:

The primary purpose of the job position is to direct the day-to-day functions of the Center in accordance with current federal, state, and local standards, guidelines, and regulations that govern nursing Centers to assure that the highest degree or quality care can be provided to residents at all times.

Administrative Functions included but not limited to: develop and maintain written policies and procedures and professional standards of practice that govern the operation of the Center; review the Center's policies and procedures at least annually and make changes as necessary to assure continued compliance with current regulations; interpret the Center's policies and procedures to employees, residents, family members, visitors, government agencies, [etcetera] as necessary; ensure all employees, residents, visitors, and general public follow the Center's established policies and procedures; assume the administrative authority, responsibility and accountability of directing the activities and programs of the Center.

Safety and Sanitation included but not limited to: review accident/incident reports (falls, injuries of unknown source, abuse [etcetera]. Monitor to determine the effectiveness of the Center's risk management.

Resident Rights included but not limited to: review resident complaints and grievances and make written reports of action taken. Discuss such actions with residents and family as appropriate; review complaints and grievances made by the resident and make a written/oral report to Nurse Supervisor/Charge Nurse. Follow Center's established procedures; maintain a written record of resident's complaints and/or grievances that indicates the action taken to resolve the complaint and the current status of the complaint; report all allegations of resident abuse and/or misappropriation of resident property.

On 6/3/24 at 10:58 AM, the surveyor interviewed Resident #79 who stated CNA #1 made sexual comments towards them that made them feel uncomfortable; that staff including a Nursing Aide (NA) who witnessed the interaction. The resident stated the facility was aware of the incident, and the LNHA had not spoken to them.

On 6/5/24 at 8:26 AM, the surveyor interviewed the NA who confirmed she had witnessed the incident between Resident #79 and CNA #1, that she initially thought they were joking until the resident reported it made them feel a certain way. The NA stated it was reported to the SW who spoke to the resident. The NA stated the incident happened maybe one month ago, but the facility had just asked for a statement.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 34 315135 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315135 B. Wing 06/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Crest Pointe Rehabilitation and Healthcare Center 1515 Hulse Road PT Pleasant, NJ 08742

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 0835 On 6/5/24 at 10:28 AM, the surveyor interviewed the SW who stated the LNHA was the Grievance Officer, and confirmed Resident #79's concern regarding sexual abuse was handled as a grievance and not an Level of Harm - Immediate investigation. The SW reported the LNHA was aware of the situation. jeopardy to resident health or safety On 6/5/24 at 10:55 AM, the surveyor interviewed the LNHA who stated their role was to oversee all department heads as well as the facility in general. The LNHA confirmed he was the Grievance Officer with Residents Affected - Some the assistance of the SW, and grievances were reviewed weekly at a meeting or sooner if needed. The LNHA confirmed he recalled the situation with Resident #79, and the SW spoke to both parties. The surveyor reviewed the grievance dated 5/16/24 with the LNHA who acknowledged poor service interaction with CNA #1 was not sufficient information. The surveyor asked the LNHA why he spoke to the resident on 6/3/24, regarding the incident that was previously reported on 5/16/24, and the LNHA stated during a meeting, staff informed him to speak to the resident. The LNHA stated that all allegations of abuse were investigated and reported to the New Jersey Department of Health (NJDOH), but the LNHA could not speak to the specifics of how the facility investigated abuse and stated he needed to review the policy.

On 6/5/24 at 2:27 PM, the facility was made aware of an IJ situation which resulted from Resident #79's allegation of verbal sexual abuse when the facility was aware of the incident between CNA #1 and the resident, and CNA #1 continued to work twelve shifts having contact with other residents with no investigation.

On 6/6/24 at 8:23 AM, the LNHA in the presence of the Director of Nursing (DON) stated he was not aware of the incident with Resident #79 and CNA #1 until 6/3/24, which contradicted the LNHA's previous interview.

The LNHA again confirmed he was the Grievance Officer and could not recall exactly when he reviewed the grievance.

On 6/6/24 at 10:02 AM, the LNHA informed the survey team again he was unaware of the resident's grievance until 6/3/24. The LNHA confirmed again his role was to oversee the operations of the facility, and his role as the Grievance Officer was to review all grievances, but the incident was never brought to his attention. The LNHA confirmed all grievances were typically reviewed on Wednesdays.

On 6/7/24 at 9:09 AM, the Regional LNHA, in the presence of the LNHA, DON, and survey team stated while inserviced staff on abuse yesterday, it was brought to their attention from the Business Office Manager (BOM), that the facility should speak to Resident #60 regarding a complaint about Unit Manager/Licensed Practical Nurse (UM/LPN) and that the LNHA was made aware at the time. The Regional LNHA stated the LNHA placed himself on administrative leave until he was trained on abuse, and then returned to the facility as the administrator.

At that time, the surveyor asked the LNHA if he was aware of the situation, and he responded that he never spoke to the resident, but he was aware the resident wanted more help with activities of daily living. The LNHA then asked the UM/LPN to speak to the resident. The LNHA confirmed the incident was not investigated and the Regional LNHA confirmed the UM/LPN was not in the facility.

On 6/7/24 at 9:25 AM, the surveyor interviewed Resident #60 who confirmed the UM/LPN had scolded and yelled at the resident for asking staff for help. The resident stated this caused increased anxiety as well as fear for who was going to help them.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 34 315135 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315135 B. Wing 06/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Crest Pointe Rehabilitation and Healthcare Center 1515 Hulse Road PT Pleasant, NJ 08742

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 0835 On 6/7/24 at 12:40 PM, the facility was made aware of a second IJ situation which resulted from Resident #60's concern regarding verbal abuse which the BOM made the LNHA immediately aware of, and the Level of Harm - Immediate UM/LPN continued to work in the facility until 6/6/24, when the incident was brought to the Regional LNHA jeopardy to resident health or and DON's attention. safety

This resulted in an second concern for the IJ situation that began on 5/16/24 after CNA #1 made sexually Residents Affected - Some inappropriate comments to Resident #79 which was reported to the SW, and continued to work twelve additional shifts. The facility Administration was notified of the additional IJ concern on 6/7/24 at 12:42 PM.

The facility submitted an acceptable Removal Plan (RP) on 6/8/24 at 8:01 AM. The survey team verified the implementation of the RP during the continuation of the on-site survey on 6/10/24.

On 6/10/24 at 9:15 AM, the Regional LNHA in the presence of the DON informed the survey team that the governing body removed the immediate threat by suspending the LNHA, and now the Regional LNHA was

the facility's administrator and was inserviced by the Chief Nursing Officer on the facility's policies. The Regional LNHA stated the LNHA provided commentary on his suspension notice, which the LNHA denied knowledge of the situations.

A review of the facility's undated Abuse Prevention Program policy included the administration will implement

the following protocols: 1. protect our residents from abuse by anyone including, but not necessarily limited to: facility staff .investigate and report any allegation of abuse within timeframe as required by federal requirements; protect residents during abuse investigations .

A review of the facility's undated Grievances/Complaints, Recording and Investigating policy included the administrator has been assigned the responsibility of investigating grievances and complaints to the grievance officer; upon reviewing grievance and complaint report, the grievance officer will begin an investigation into the allegation .the investigation and report will include, as applicable: the date and time of alleged incident; circumstances surrounding the alleged incident; the location of the alleged incident; the names of any witnesses and their accounts; the resident's alleged account; accounts of any other individuals involved .the grievance officer will coordinate actions with the appropriate state and federal agencies, depending on the nature of the allegations. All alleged violations of neglect, abuse will be reported and investigated under guidelines for reporting abuse .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 34 315135 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315135 B. Wing 06/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Crest Pointe Rehabilitation and Healthcare Center 1515 Hulse Road PT Pleasant, NJ 08742

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 0835 A review of the facility's Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating policy dated revised September 2022, included if resident abuse .is suspected, the suspicion must be reported Level of Harm - Immediate immediately to the administrator and to other officials according to state law; the administrator or the jeopardy to resident health or individual making the allegation immediately reports his or her suspicion to the following persons or safety agencies: the state licensing/certification agency responsible for surveying/licensing the facility .immediate is defined as within two hours of an allegation of abuse .upon receiving any allegation of abuse [ .] the Residents Affected - Some administrator is responsible for determining what actions (if any) are needed for the protection of the residents; all allegations are thoroughly investigated. The administrator initiates investigation .the administrator provides supporting documents and evidence related to alleged incident to the individual in charge of investigation .any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete; the individual conducting the investigation at minimum: a. reviews the documentation and evidence; .d. interviews the person (s) reporting the incident; e. interviews any witnesses to the incident; interviews the resident [ .]; j. interviews other residents to whom the accused employee provides care or services; .l. documents the investigation completely and thoroughly. The following guidelines are used when conducting interviews: .witness statements are obtained in writing, signed and dated .

NJAC 8:39-9.2(a)

NJAC 8:39-9.3(a)

NJAC 8:39-27.1(a)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 34 315135 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315135 B. Wing 06/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Crest Pointe Rehabilitation and Healthcare Center 1515 Hulse Road PT Pleasant, NJ 08742

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 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or 38079 potential for actual harm Complaint NJ #173248 Residents Affected - Few Based on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to perform proper hand hygiene during wound care to reduce the risk of infection. This deficient practice was identified for 1 of 1 resident reviewed for wound care (Resident #4), and was evidenced by the following:

On 6/4/24 at 9:25 AM, Resident #4 was observed lying in bed on an air mattress. Resident #4 refused to be interviewed stating he/she was tired.

The surveyor reviewed the medical record for Resident #4.

A review of the Admission Record face sheet (an admission summary) reflected the resident was admitted to

the facility with diagnoses which included but were not limited to; type 2 diabetes mellitus, chronic pain, end stage renal disease, and dependence on renal dialysis.

A review of the most recent quarterly Minimum Data Set, an assessment tool dated 3/4/24, included the resident had a Brief Interview for Mental Status (BIMS) score of 13 out of 15; which indicated a fully intact cognition.

A review of the Order Summary Report included a physician's order dated 6/1/24; for Bacitracin (antibiotic) ointment 500 unit per gram (unit/gm) to apply to the left great toe topically every day shift for wound care; cleanse with normal saline solution (NSS); pat dry; apply ointment to the affected area and wrap with [name redacted] gauze wrap.

On 6/7/24 at 8:57 AM, the surveyor observed the Licensed Practical Nurse (LPN) prepare to administer Resident #4's wound care treatment. The LPN placed some antibiotic ointment into a small cup; obtained a sterile cotton tip applicator; obtained sterile gauze; and obtained the bottle of NSS. The surveyor observed

the treatment and the following:

At 9:03 AM, the LPN went into the resident's bathroom and performed hand hygiene using soap and water; then donned (put on) personal protective equipment (PPE) of a gown and gloves. The LPN removed the dressing on the resident's toe; doffed (removed) her gloves, and with no observed hand hygiene, donned a new pair of gloves. The LPN cleaned the toe with the NSS and patted the area dry; then doffed the contaminated gloves, and with no observed hand hygiene, opened the sterile cotton tip applicator and donned a new pair of gloves. The LPN used the cotton tip applicator to apply the antibiotic ointment to the wound; doffed the contaminated gloves, and with no observed hand hygiene, donned a new pair of gloves and applied the gauze dressing to the toe and foot. The LPN doffed the contaminated gloves, and with no observed hand hygiene, applied a numbing cream on the resident's hemodialysis injection area of the arm.

The LPN then doffed the contaminated gloves, and with no observed hand hygiene hygiene, donned a new pair of gloves, and placed a wrap on the hemodialysis access site. The LPN then went into the resident's bathroom and doffed the contaminated gloves; performed hand hygiene using soap and water by rubbing her hands with soap outside the flow of running water for seventeen seconds.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 34 315135 Department of Health & Human Services Printed: 09/23/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 315135 B. Wing 06/12/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Crest Pointe Rehabilitation and Healthcare Center 1515 Hulse Road PT Pleasant, NJ 08742

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 0880 On 6/7/24 at 9:13 AM, during an interview with the surveyor, the LPN stated that hand washing should be done for 15-20 seconds and stated, I guess I should do it [apply friction] outside of the water. When asked Level of Harm - Minimal harm or about hand hygiene during the wound care, the LPN acknowledged that she should have been performing potential for actual harm hand hygiene between glove changes.

Residents Affected - Few On 6/7/24 at 9:22 AM, during an interview with the surveyor, the Director of Nursing (DON) stated that the process of hand washing was to wet your hands, apply soap, and lather hands all over for at least 20 seconds outside the stream of water. The DON stated that if performed under the stream of water, you would be washing the soap off. The DON further stated that hand hygiene must be done in between glove changes to remove germs.

A review of the facility provided, Hand Hygiene Comp [competency] Validation dated 05/16/24, documented that the LPN performed a competent return demonstration of hand hygiene which was signed by the LPN and the staff member conducting the competency.

On 6/10/24 at 9:00 AM, the DON in the presence of the Regional Licensed Nursing Home Administrator and survey team acknowledged that the nurse should have performed hand hygiene after removing her gloves prior to donning new gloves. The DON also acknowledged hand hygiene using soap and water was performed by rubbing your hands with soap outside the flow of running water for twenty seconds.

A review of the facility provided policy and procedure, Handwashing/Hand Hygiene revised October 2023, included but was not limited to; Policy Statement . hand hygiene the primary means to prevent the spread of healthcare-associated infections. Administrative Practices to Promote Hand Hygiene 1.trained and regularly in-serviced on the importance . in preventing the transmission of healthcare-associated infections. 2. All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors. Indications for Hand Hygiene 1.a. immediately before touching a resident; c. after contact with . contaminated surfaces; d. after touching a resident; f. before moving from work on a soiled body site to a clean body site on the same resident; and g. immediately after glove removal. Procedure Washing Hands 1. Wet hands first . apply an amount of product recommended. 2. Rub hands together . for at least 20 seconds . 3. Rinse hands with water and dry thoroughly . Applying and removing gloves 1. Perform hand hygiene before applying gloves. 5. Perform hand hygiene [after removing gloves].

A review of the facility provided policy and procedure, Wound Care revised October 2010, included but was not limited to; Purpose . to provide guidelines for the care of wounds to promote healing. Steps in the Procedure 2. Wash and dry your hands thoroughly. 4. Put on exam gloves. Loosen tape and remove dressing. 5. discard into appropriate receptacle. Wash and dry your hands thoroughly. 6. Put on gloves. 7. Use sterile tongue blades and applicators to remove ointments from their containers. 8. Pour liquids directly

on gauze . 12. apply treatments as indicated. 13. Dress wound. 15. Discard disposable items. Remove gloves and discard . wash and dry your hands thoroughly.

NJAC 8:39-19.4 (a)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 34 315135