Crest Pointe Rehabilitation And Healthcare Center
CREST POINTE REHABILITATION AND HEALTHCARE CENTER in PT PLEASANT, NJ — inspection on June 12, 2024.
Found 10 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
The survey team verified the implementation of the RP during the continuation of the on-site survey on 6/8/24.
NJAC 8:39-4.1(a)5
315135 06/12/2024
Crest Pointe Rehabilitation and Healthcare Center 1515 Hulse Road PT Pleasant, NJ 08742
the NJDOH within two hours.
This incident was not reported to the NJDOH until 6/6/24.
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 all alleged violations of neglect, abuse [ ] will be reported and investigated under guidelines for reporting abuse .
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 immediately to the administrator and to other officials according to state law; the administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: the state licensing/certification agency responsible for surveying/licensing the facility .immediate is defined as within two hours of an allegation of abuse .
NJAC 8:39-4.1(a)5
315135 06/12/2024
Crest Pointe Rehabilitation and Healthcare Center 1515 Hulse Road PT Pleasant, NJ 08742
need assistance finding a location as they will appeal the denial for long term care Medicaid.
The note
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.
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 .
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
315135 06/12/2024
Crest Pointe Rehabilitation and Healthcare Center 1515 Hulse Road PT Pleasant, NJ 08742
2/2023, included the purpose: hemodialysis catheters will only be accessed by medical staff who
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)
315135 06/12/2024
Crest Pointe Rehabilitation and Healthcare Center 1515 Hulse Road PT Pleasant, NJ 08742
of the sheet revealed the following:
19 shifts in December 2023; 12 shifts in January 2024; 17 shifts February 2024; 20 shifts March 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)
315135 06/12/2024
Crest Pointe Rehabilitation and Healthcare Center 1515 Hulse Road PT Pleasant, NJ 08742
services of a licensed pharmacist.
facility failed to ensure an accurate ordering and receiving of narcotic medications on the required
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)
315135 06/12/2024
Crest Pointe Rehabilitation and Healthcare Center 1515 Hulse Road PT Pleasant, NJ 08742
serve food in accordance with professional standards.
hazardous food was stored in a sanitary manner.
The deficient practice was evidenced by the
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)
315135 06/12/2024
Crest Pointe Rehabilitation and Healthcare Center 1515 Hulse Road PT Pleasant, NJ 08742
policies.
The Regional LNHA stated the LNHA provided commentary on his suspension notice, which
jeopardy to resident health or safety 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
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 .
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 immediately to the administrator and to other officials according to state law; the administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or 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 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)
315135 06/12/2024
Crest Pointe Rehabilitation and Healthcare Center 1515 Hulse Road PT Pleasant, NJ 08742
have been performing hand hygiene between glove changes.
that the process of hand washing was to wet your hands, apply soap, and lather hands all over for at
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.
- 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)
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.
315135
Form Approved OMB
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
Frequently Asked Questions
More Reports
Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.