Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Careone At Cresskill during CMS and state inspections, most recent first.
A facility failed to include the bed hold reserve payment amount in written emergency transfer notices for 3 residents who were hospitalized. The transfer letters stated that each resident was entitled to a 10-day bed-hold privilege, but they did not list the reserve payment amount and also referenced insurance the facility did not participate in. One resident had DM and HF, another had orthopedic aftercare and a humerus fracture, and a third had AFib and hypertensive heart disease with HF.
A resident with hydrocephalus, a prior subarachnoid hemorrhage, coordination deficits, dysphagia, and moderately impaired cognition was observed seated in a specialized w/c with the call bell wrapped around the bed side rail and not within reach. The resident could not locate the call bell when asked, and an LPN acknowledged the resident could not reach it and that it should not have been wrapped around the side rail; the resident also had limitations in both upper and lower extremities.
Failure to provide required Medicare non-coverage notice: A resident remained in the facility after signing a NOMNC ending Medicare A coverage, but the SNFABN was not provided in writing. The RN/MDSC stated the SNFABN was her responsibility and that it was usually given only after the resident decided to stay, while the LNHA later said another NOMNC should have been done but was not shown and that no SNFABN was issued because there was no financial liability.
Inadequate monitoring and inappropriate diagnosis for antipsychotic use: A resident with severe cognitive impairment and dementia-related behaviors received quetiapine and divalproex, but the MDS did not show an active diagnosis for the antipsychotic, the care plan did not list target behaviors, and behavior monitoring was not documented when the antipsychotic was started or increased. The psych APRN described restlessness in the evenings without aggression or psychotic symptoms, while the LPN, UM, and DON stated that target behaviors and monitoring should be documented and that restlessness and agitation were not appropriate diagnoses for the antipsychotic.
Failure to Transmit Completed MDS: A resident’s DRNA MDS was completed but not transmitted within the required timeframe. The RN/MDSC confirmed the MDS should have been sent and was unsure of the applicable deadline, and later stated there were no transmission reports because it had not been transmitted. The DON and LNHA were notified of the finding.
MDS assessments did not accurately code diagnoses related to psychotropic meds for four residents. The RN/MDSC said she reviewed psych notes, meds, and diagnoses for coding, but the MDSs still left Section I blank for antidepressant and antipsychotic indications even though records showed orders and psych consults for depression, anxiety, mood disorder, agitation, and adjustment disorder.
Incomplete psychotropic medication monthly documentation was found for a resident with hydrocephalus, subarachnoid hemorrhage, coordination problems, dysphagia, and moderately impaired cognition. The PMMN entries did not match the psychiatric consult note or eMAR, listed incorrect target behaviors such as depressed mood and psychosis instead of restlessness, and omitted required episode counts and a psychiatry consult date. The DON stated nurses were responsible for the notes and that the documentation should match the reviewed month and the resident’s monitored behavior.
Pressure ulcer treatment, documentation, and hand hygiene failures: A resident with severe cognitive impairment and facility-acquired heel and buttock pressure injuries had missing eTAR signatures for ordered wound care, no timely CP for the heel wound, and no CP for the buttock wound. During observed wound care, an LPN used a handwashing method that did not match policy, and a CNA returned room items to the treatment cart without disinfecting them. Staff confirmed the documentation gaps and improper hand hygiene process.
A resident with type 2 DM, gait and mobility impairment, and severely impaired cognition had multiple falls, but new interventions were not implemented and documented in the care plan in a timely manner after several of the events. Records showed delayed additions such as a med review, a directive not to leave the resident unattended in the shower, psych consult, and dycem to the wheelchair, while one fall had no new intervention documented and the care plan did not reflect the resident’s actual falls.
A resident with a PEG tube and severe cognitive impairment received enteral feeding at 50 ml/hr, but staff did not document the actual volume infused each shift. The eMAR showed a flush order for 125 ml q6h that was plotted three times daily instead of q6h, and the enteral feed order was not clarified despite staff signing that 1200 ml had been infused in 24 hours.
A facility failed to post an accurate NHRCSR daily for 2 of 5 observed days. Surveyors found a posted staffing report in the lobby that was dated the prior day and listed an incorrect resident census, and on another day the posted census of 75 did not match the midnight census of 74 confirmed by the Regional Nurse. The DON and LNHA acknowledged the discrepancy, and the facility policy required daily posting of staffing data including the resident census.
A resident with type 2 DM, gait and mobility abnormalities, and severe cognitive impairment did not receive a documented monthly medication regimen review from the pharmacy consultant for one month. The PC binder showed only the initial admission EPIC review, and the DON stated the resident was in the hospital when the PC visited that unit, leaving no documented February MRR.
Medication Administration Error Rate Exceeded Allowed Threshold: Surveyors observed an LPN preparing meds for a resident with cognitively intact status and active orders for PreserVision and Saccharomyces boulardii. The LPN selected multivitamin with minerals tablets instead of PreserVision capsules and Probiotic Acidophilus instead of the ordered probiotic, contributing to an 8% med administration error rate during the observed med pass.
Surveyors found medication labeling and storage deficiencies in two med carts. An unlabeled foil package of albuterol/ipratropium inhalation solution vials was stored in one cart without its original box, and a Humalog insulin pen in another cart had no date of first use or disposal date. The LPN and RN both confirmed the items should have been labeled or dated, and the facility policy required meds to be stored in the packaging in which they are received and opened multi-dose vials to be dated.
Inaccurate documentation of 1 to 1 observation: A resident with hypertensive heart disease and acute myeloblastic leukemia had a grievance-related schedule showing CNA coverage, but the CNA assignment sheet, care plan, and PN did not document any 1 to 1. Staff gave conflicting explanations about whether the 1 to 1 was for safety, suicidal ideation, or simply a temporary companion/customer service arrangement, and the LNHA stated there was no policy for 1 to 1 documentation.
A resident with hydrocephalus, prior subarachnoid hemorrhage, coordination problems, dysphagia, and moderately impaired cognition had no documented influenza vaccine consent, refusal, or ineligibility after the last recorded consent from the prior season. The EMR and paper chart showed the last flu vaccine was given previously, but there were no consent forms or documentation that the RR was contacted for later seasons. The LPN and RN/IPN confirmed the missing documentation, and the facility policy required annual flu vaccination documentation and refusal recording.
The facility failed to provide sufficient nursing staff and timely call bell responses, as reported by residents and confirmed by staff interviews. Residents experienced delays in assistance due to short staffing, particularly during the 3-11 and 11-7 shifts. The facility did not meet New Jersey's mandated staffing ratios, with CNAs responsible for up to 19 residents during the night shift. Grievance reports and staffing assignments further highlighted these deficiencies.
The facility was found deficient in infection control practices, including improper hand hygiene by two LPNs during medication administration, inadequate disinfection of equipment between residents by an LPN, and improper use of disinfecting wipes by an RN. Additionally, a Housekeeping staff member failed to wear full PPE, including eye protection, when entering the room of a COVID-19 positive resident, despite clear signage. These actions were contrary to the facility's policies and CDC guidelines.
The facility failed to accurately code the MDS for two residents, leading to deficiencies in their care assessments. One resident's MDS was completed remotely without an in-person interview, inaccurately reflecting adequate hearing despite observed hearing difficulties. The second resident's MDS did not include a required cognitive interview, despite the resident being sometimes understood. These issues were acknowledged by facility management.
A Registered Nurse in a long-term care facility administered a 500 mg tablet of Ascorbic Acid instead of the prescribed two 250 mg tablets due to unavailability, without consulting the physician. This action was against the facility's policy, which requires medications to be administered as prescribed.
A resident experienced an allergic reaction and requested to be sent to the hospital, but the nurse on duty did not honor this request. Instead, the nurse administered Benadryl without a physician's order and failed to notify the DON or the resident's representative. The resident self-administered an epinephrine pen, which improved their condition. The facility's investigation found that the nurse did not follow proper procedures for medication administration and resident rights.
A resident with end-stage renal disease had medications scheduled during their dialysis sessions, leading to a deficiency in care. Despite the resident's dialysis schedule, medications were signed as administered at times when the resident was not present at the facility. The LPN and RN/UM acknowledged the need to adjust medication times, but the facility's policies did not address this issue, contributing to the deficiency.
The facility failed to maintain accurate medical records for two residents, leading to deficiencies in care. One resident's medication was inaccurately documented, while another had unclear fluid restriction instructions. The facility's policy requires accurate documentation, but entries were not reviewed and updated, resulting in incomplete records.
A facility failed to complete a Significant Change in Status Assessment (SCSA) for a resident who revoked hospice care, as required by CMS guidelines. The resident, with multiple diagnoses including Parkinsonism and dementia, was initially in hospice for end-stage polycystic kidney disease. The MDS Coordinator admitted the oversight, and facility management confirmed the SCSA was not completed.
Bed Hold Payment Amount Omitted From Transfer Notices
Penalty
Summary
The facility failed to include the bed hold reserve payment amount in the written emergency transfer notifications provided to resident representatives for 3 of 3 residents reviewed for hospitalization. For Resident #3, who had diagnoses including type 2 diabetes mellitus and heart failure and whose cognitive skills for daily decision making were modified independence, the record showed a transfer to a short-term general hospital. The letter to the resident’s representative stated that the resident was transferred for a higher level of care and that every resident was entitled to a ten-day bed-hold privilege, but it did not include the bed hold reserve payment amount and also referenced an insurance the facility did not participate in. For Resident #33, whose diagnoses included orthopedic aftercare and an unspecified fracture of the upper end of the right humerus and whose cognitive skills for daily decision making were intact, the record showed hospital transfers on two occasions. The letters to the resident and resident representative dated for those transfers stated that the resident was transferred for a higher level of care and that every resident was entitled to a ten-day bed-hold privilege, but they did not include the bed hold reserve payment amount. Those letters also included information related to an insurance that the facility did not participate in. For Resident #93, whose diagnoses included paroxysmal atrial fibrillation and hypertensive heart disease with heart failure, the record showed an unplanned discharge to a hospital. The Notice of Transfer to Acute Care Facility did not include any information reflecting the amount of reserve bed hold payment, and the admission agreement’s bed hold policy also did not reflect the amount of reserve bed hold payment. The facility’s Bed-Holds and Returns Policy referenced the reserve bed payment policy as indicated by the state plan, but it did not reflect any mention of bed hold reserve payment amounts or notification of reserve bed hold payment amounts with every acute transfer.
Call Bell Not Within Reach
Penalty
Summary
The facility failed to ensure that one resident’s call bell was within reach and usable to accommodate the resident’s needs. During observation, the resident was seated in a specialized wheelchair in the room while the call bell was wrapped around the side rail of the bed and not accessible. When asked, the resident was unable to locate the call bell, and a CNA removed it from the side rail and placed it in the resident’s left hand under the blanket. The assigned LPN stated that the resident was unable to reach the call bell and acknowledged that it should not have been wrapped around the side rail. The resident had diagnoses including hydrocephalus, nontraumatic subarachnoid hemorrhage, lack of coordination, and dysphagia. The most recent MDS showed a BIMS score of 10 out of 15, indicating moderately impaired cognition, and the LPN stated the resident had limitations to both upper and lower extremities. The facility’s documentation also reflected that the resident’s call bell arrangement was later assessed by OT, who noted the resident could retrieve and press the call bell and that it should be clipped to the wheelchair and positioned in the resident’s lap when seated.
Failure to Provide Required Medicare Non-Coverage Notice
Penalty
Summary
The facility failed to complete in writing the required beneficiary notice for Resident #106. The SNF Beneficiary Protection Notification review showed that the resident’s last covered Medicare A day was 10/5/25 and that the resident remained in the facility, with a Notice of Medicare Non-Coverage (NOMNC) signed by the resident on 10/2/25 indicating Medicare coverage for skilled nursing services would end on 10/5/25. The review also showed that a Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) was not provided. During the survey, the RN/MDS Coordinator stated that the NOMNC was prepared by the SW and that the SNFABN was her responsibility, and she said the SNFABN was sometimes given at the same time as the NOMNC but most often was provided once the resident or representative decided to stay at the facility. The resident had remained in the facility for five more days after signing the NOMNC, and the RN/MDS Coordinator later provided appeal paperwork showing the resident had appealed twice, while stating she was unsure whether another NOMNC had been done. The LNHA later stated that another NOMNC should have been done but was not presented to the surveyor, and also stated there was no financial liability, which was why no SNFABN was provided.
Inadequate monitoring and inappropriate diagnosis for antipsychotic use
Penalty
Summary
The facility failed to adequately monitor target behaviors for a psychotropic medication and failed to ensure an antipsychotic medication was ordered for an appropriate diagnosis for one resident. The resident had severe cognitive impairment with a BIMS score of 00 out of 15 and diagnoses that included type 2 diabetes mellitus and abnormalities of gait and mobility. The resident was observed lying in a bed low to the ground, and the resident representative stated the resident had fallen two times. The resident’s MDS showed receipt of an antipsychotic medication, but no active diagnosis was documented for the medication. The care plan included risk for adverse effects related to antipsychotic and anxiolytic use, but it did not include target behaviors to be monitored. The January eMAR/TAR showed quetiapine and divalproex orders, including quetiapine for agitation and mood disorder with behavior, and there was no other behavior monitoring documented for quetiapine or divalproex during that month. The February eMAR/TAR showed quetiapine ordered every 8 hours for mood disorder, later changed to target symptoms of restlessness and agitation, with behavior monitoring entries for paranoia and restlessness to exhaustion, but the medication was increased without any behavior monitoring documented. The psychiatric APRN documented that the resident had dementia with behavioral disturbance, mood disorder NOS, and delirium or sundowning, and noted the resident was cooperative with treatment and medications, frequently restless in the evenings, and without aggression, exit-seeking behaviors, or psychotic symptoms. The APRN increased quetiapine and instructed continued monitoring and documentation of moods and behaviors. During interviews, the LPN, UM, and DON stated that residents on antipsychotics should have target behaviors and behavior monitoring documented, and that the diagnosis of restlessness and agitation was not appropriate for an antipsychotic. The DON later stated that behavior monitoring had not been restarted after the resident returned from the hospital and that the order for restlessness and agitation should have been clarified.
Failure to Transmit Completed MDS
Penalty
Summary
The facility failed to complete and transmit the MDS within the required timeframe for Resident #80. The resident had a DRNA MDS with an ARD of 10/30/25 that was completed, but the surveyor found that it had not been accepted or transmitted. The RAI Manual cited in the report states that for a discharge MDS return not anticipated, the MDS completion date is the discharge date plus 14 calendar days, and the transmission date is the MDS completion date plus 14 calendar days. During the survey, the RN/MDS Coordinator confirmed that the DRNA MDS had been completed but not transmitted and stated that the 10/30/25 MDS should have been transmitted. She also stated she was unsure whether the completed MDS was required to be transmitted within seven or 14 days. Later, she stated there were no transmission reports for Resident #80 because the DRNA MDS was not transmitted. The LNHA and DON were notified of the findings, and the DON later stated that Resident #80's MDS was transmitted after the surveyor's inquiry.
MDS assessments did not accurately code psychotropic medication diagnoses
Penalty
Summary
The facility failed to accurately complete portions of the MDS for 4 of 22 residents reviewed, with the assessments not reflecting residents’ status as of the ARD. For Resident #7, the Admission/Medicare 5 Day MDS and Quarterly MDS showed a BIMS score of 12 out of 15 and captured antidepressant and antipsychotic medications in Section N, but Section I did not include diagnoses related to those psychotropic medications. The record showed diagnoses including metabolic encephalopathy and a right femur fracture, physician orders for olanzapine and paroxetine, and psychiatric consults stating to continue Paxil for depression/anxiety and Zyprexa for mood disorder, with target symptoms of restlessness and agitation. For Resident #33, the Significant Change MDS showed a BIMS score of 15 out of 15 and captured an antidepressant in Section N, but Section I did not include depression. The record showed diagnoses including orthopedic aftercare and an unspecified fracture of the upper end of the right humerus, a physician order for trazodone at bedtime for depression, and a psychiatric consult documenting adjustment disorder with depression and anxiety and continuing trazodone for depression. For Resident #54, the Admission/Medicare 5 Day MDS showed a BIMS score of 15 out of 15 and captured an antidepressant in Section N, but Section I did not include a diagnosis for the antidepressant. The record showed diagnoses including surgical aftercare following digestive system surgery and diverticulitis with perforation and abscess, along with orders for escitalopram and mirtazapine and a psychiatric consult diagnosing adjustment disorder with depression and changing antidepressant therapy. For Resident #99, the comprehensive MDS showed a BIMS score of 00 out of 15 and captured an antipsychotic in Section N, but Section I did not include an active diagnosis for the antipsychotic medication. The resident’s admission record listed type 2 diabetes mellitus and abnormalities of gait and mobility. During interview, the RN/MDS Coordinator stated she reviewed psychiatry notes, medications, and diagnoses and would code medications in Section N and diagnoses in Section I, and then acknowledged that the four MDSs were completed in error and that diagnoses for antidepressants and antipsychotics should have been coded.
Incomplete Psychotropic Medication Monthly Documentation
Penalty
Summary
The facility failed to thoroughly complete the psychoactive medication monthly note and failed to accurately document the target behavior being monitored for Resident #81, who was reviewed for unnecessary medications. Resident #81 was observed seated in a specialized wheelchair and watching a movie on a tablet, and the assigned LPN stated the resident was able to make needs known to staff. The resident’s record showed diagnoses including hydrocephalus, nontraumatic subarachnoid hemorrhage, lack of coordination, and dysphagia, and the most recent MDS reflected moderately impaired cognition with a BIMS score of 10 out of 15. The psychiatric follow-up notes stated that Depakote was to be continued for mood disorder NOS, with prior dose reduction having increased restlessness and later dose increase improving nighttime restlessness. The Psychoactive Medication Monthly Note for one review month documented the target behavior as depressed mood, but no corresponding number of episodes was recorded, and the date of last psychiatry consult was 11/28/25. Another monthly note documented the target behavior as psychosis, but again no corresponding number of episodes was recorded, and the date of last psychiatry consult was left blank. The DON stated that nurses were responsible for documenting the monthly psychotropic notes in the electronic medical record and that the note should match the eMAR and psychiatric consult note targeted behavior of restlessness. The DON also stated that the effective date should reflect the month being reviewed rather than the current month. The facility’s psychotropic medication use policy stated that residents should not receive psychotropic medications that are not clinically indicated and necessary to treat a specific condition documented in the medical record, and that monitoring may include behavior flow sheets and MARs.
Pressure ulcer treatment, documentation, and hand hygiene failures
Penalty
Summary
The facility failed to ensure appropriate pressure ulcer care for a resident with significant cognitive impairment and multiple diagnoses including Alzheimer’s disease, generalized muscle weakness, gait abnormalities, and a history of falls. The resident’s record showed facility-acquired pressure ulcers involving the left heel and right buttock, with wound documentation reflecting a left heel deep tissue injury and a right buttock unstageable wound that later progressed to a stage 2 pressure injury. The wound nurse documented the wounds and notified the physician and resident representative, and physician orders were entered for heel and buttock wound care, air mattress use, and turning every 2 hours. The record review showed missing documentation of ordered wound treatments in the eTAR. There was no signed treatment for the left heel on one date, and no signed treatment for the right buttock on another date, and there was no nursing progress note showing the right buttock treatment was rendered. The care plan was also not developed in a timely manner for the left heel wound, being initiated 12 days after the wound was identified, and there was no care plan initiated for the right buttock pressure ulcer. Facility staff confirmed the eTAR should have been signed and that the care plan should have been started earlier, but could not explain why the right buttock care plan was absent. During direct observation of wound treatment, the surveyor observed the LPN perform handwashing by applying soap before wetting her hands, which was inconsistent with the facility’s hand hygiene policy requiring hands to be wet first. The surveyor also observed a CNA bring gloves, disinfectant, and ABHR into the resident’s room and then remove those items back to the treatment cart without disinfecting them. The LPN confirmed she did not know the correct handwashing sequence and stated that items brought into the resident’s room should not come out, and she confirmed the items were not disinfected before being returned to the cart.
Delayed fall interventions and care plan updates
Penalty
Summary
The facility failed to ensure that a new intervention was implemented and documented in the resident’s care plan in a timely manner after multiple falls for one resident reviewed for falls. Resident #99 was admitted with diagnoses including type 2 diabetes mellitus and abnormalities of gait and mobility, and the most recent cMDS showed a BIMS score of 00 out of 15, indicating severely impaired cognition. The resident was observed lying in a bed low to the ground, and the resident representative stated the resident had fallen two times. A review of five fall incidents showed that after the resident was found on the floor or had a fall, care plan interventions were added several days later in some instances. After the resident was observed laying on the floor in the lounge, the care plan was updated nine days later with a medication review. After the resident was found sitting on the shower floor, the care plan was updated five days later with an intervention not to leave the resident unattended in the shower. After another fall, the record showed no new intervention was implemented. After a later fall, a psych consult was added the next day, and after another fall involving a chair alarm and sliding to the floor, dycem to the wheelchair was added seven days later. The individualized care plan included a fall-risk focus area with interventions such as therapy, slow transfers, easy access to commonly used items, assistance with transfers and ambulation, call-for-help reinforcement, bed and chair alarms, medication review, psych eval, and dycem to the wheelchair. However, the care plan did not indicate that the resident had actual falls, and the intervention of not leaving the resident unattended was not included. Staff interviews reflected that the nurse documented the fall and risk management, and that the multidisciplinary team and leadership typically met the following day to decide on interventions, but the documented interventions for this resident were delayed after the falls.
Enteral Feeding Order and Documentation Not Properly Managed
Penalty
Summary
The facility failed to ensure that enteral feeding was provided and documented in accordance with standard of practice for a resident with a gastrostomy tube. Resident #12 was admitted with diagnoses including gastrostomy and Down syndrome, and the most recent MDS reflected a BIMS score of 00, indicating severe cognitive impairment. During observation, the resident was in bed with the head of bed elevated and receiving enteral feed via pump at 50 ml/hr; the pump showed 877 ml infused with 323 ml remaining. The resident’s eMAR included an enteral feed order for Jevity 1.2 at 50 ml/hr with a total nutrient amount of 1200 ml starting at 4 PM and running until 1200 ml had infused, but the nurses signed the feed as administered without documenting the actual total volume infused each shift. The record also showed a flush order for 125 ml every 6 hours, but it was plotted three times a day rather than every 6 hours, and the order did not specify what fluid was to be used. The LPN stated that the enteral feed was hung in the evening and finished when the total volume of 1200 ml was reached, and the DON stated that nurses signed off that 1200 ml were infused in 24 hours. The surveyor questioned how the resident could receive 1200 ml in 24 hours when the feed would need to be stopped for care, and the LNHA acknowledged the concern. The facility policy stated that adequate nutritional support through enteral nutrition is provided as ordered, but it did not contain information about documenting amount infused.
Inaccurate Daily Staffing Report Posting
Penalty
Summary
The facility failed to post an accurate Nursing Home Resident Care Staffing Report daily for 2 of 5 days observed. On 3/12/26 at 8:19 AM, the surveyor observed a posted staffing report in the lobby dated 3/11/26 that listed the census as 74 for all shifts and showed a CNA-to-resident ratio of 1:8.2 for the 7:00 AM to 3:00 PM shift. The receptionist stated that visiting hours were from 8:00 AM to 8:00 PM, and the DON later confirmed that the facility census was 74. On 3/16/26 at 9:25 AM, the surveyor observed another posted staffing report dated 3/16/26 showing a census of 75 for the day, evening, and night shifts. However, a review of the Midnight Census report at 12:51 PM showed the census was 74, and the Regional Nurse confirmed that the census was 74. During meetings with the LNHA and DON on 3/17/26 and 3/19/26, the LNHA stated that the census was being reconciled and acknowledged that the posted NHRCSR should have reflected 74 instead of 75 on 3/16/26. The facility policy required daily posting of staffing data, including the resident census at the beginning of the shift, and the facility did not refute the findings.
Missing Monthly Pharmacy Medication Review
Penalty
Summary
The facility failed to ensure that Resident #99 received a monthly medication review from the pharmacy consultant for February 2026. Resident #99 was admitted with diagnoses including type 2 diabetes mellitus and abnormalities of gait and mobility, and the most recent cMDS showed a BIMS score of 00 out of 15, indicating severe cognitive impairment. The MDS also reflected that the resident received an antipsychotic medication. A review of the pharmacy consultant binder showed an EPIC review completed on 1/9/26 for the initial admission medication orders, but no other monthly medication review was documented during the resident’s stay. A progress note in the medical record showed that the pharmacy consultant completed a medication regimen review on 3/9/26, but there was no documented evidence of a review for February 2026. The DON stated that the pharmacy consultant reviewed residents on one unit on one day and returned another day for the other unit, and later stated that Resident #99 did not have a medication regimen review in February because the resident was in the hospital on the day the pharmacy consultant was at the facility. The LNHA did not provide additional information.
Medication Administration Error Rate Exceeded Allowed Threshold
Penalty
Summary
The facility failed to ensure that medication administration error rates remained below 5 percent. During observation of medication passes involving 3 nurses and 3 residents, surveyors identified 2 errors out of 25 opportunities, resulting in an 8% medication administration error rate. The deficiency was identified during the medication pass of one resident, where an LPN prepared medications that did not match the active physician orders displayed on the eMAR. For that resident, the active orders included PreserVision capsule 1 cap by mouth twice daily and Probiotic oral cap (Saccharomyces boulardii) 1 cap by mouth once daily. The LPN selected and prepared a bottle labeled multivitamin with minerals tablets instead of PreserVision capsules, and a bottle labeled Probiotic Acidophilus capsules instead of the ordered probiotic. The resident’s EMR showed diagnoses including osteoarthritis and osteoporosis, and the cMDS reflected a BIMS score of 15 out of 15, indicating the resident was cognitively intact. The consultant pharmacist stated that PreserVision and regular multivitamins with minerals were not confirmed to be interchangeable, and that Saccharomyces boulardii and Acidophilus were different types of probiotics.
Medication Labeling and Storage Deficiencies in Med Carts
Penalty
Summary
The facility failed to properly store and label medications in 2 of 4 medication carts observed during surveyor inspection. In the northwest med cart, the surveyor found a sealed foil package containing albuterol/ipratropium inhalation solution vials that did not have a pharmacy label, and no matching box for the medication was located in the cart. The LPN confirmed that the medication should have had a label or its original box and removed the foil pouch from the cart. In the northeast med cart, the surveyor observed a Humalog insulin pen inside a plastic bag with no date of first use or disposal date written on the bag or on the device label. The label showed the pen had been dispensed by the pharmacy on 1/27/26. The RN stated the insulin pen should have been dated when placed in the med cart and removed it from the cart. The facility policy stated medications are stored in the packaging in which they are received and that opened or accessed multi-dose vials are dated and discarded within 28 days unless the manufacturer specifies otherwise.
Inaccurate Documentation of 1 to 1 Observation
Penalty
Summary
The facility failed to maintain an accurate medical record for one resident reviewed. The record for the resident, who had diagnoses including hypertensive heart disease and acute myeloblastic leukemia, was reviewed in connection with a grievance about a 1 to 1 being late and another grievance about a call bell being unplugged. The grievance binder contained a schedule listing CNA coverage for the resident on multiple dates, but the North Station CNA assignment sheet did not show any resident assigned to a 1 to 1, and the resident’s comprehensive care plan and progress notes did not document that the resident was on a 1 to 1. During interviews, the LPN stated that a 1 to 1 would be used if a resident was not safe or tried to leave, and the UM stated it would be documented somewhere, likely in progress notes, and should be in the care plan. The DON stated that a 1 to 1 would be provided for suicidal ideation or self-harm and that if physically needed it should be in the care plan. Later, the UM stated the 1 to 1 may have been a temporary companion arrangement provided by the facility, while the DON stated the previous administration described it as customer service and unrelated to resident safety. The LNHA stated the facility did not have a policy regarding 1 to 1 documentation and did not provide additional information.
Failure to Document Influenza Vaccine Consent or Refusal
Penalty
Summary
The facility failed to offer an influenza vaccine or document a refusal or reason for ineligibility for one resident reviewed for unnecessary medications. The resident had diagnoses including hydrocephalus, nontraumatic subarachnoid hemorrhage, lack of coordination, and oropharyngeal dysphagia. The most recent MDS showed a BIMS score of 10 out of 15, indicating moderately impaired cognition, and the resident was observed seated in a specialized wheelchair while watching a movie on a tablet. Review of the medical record showed the last influenza vaccine was administered on 10/26/23. The paper chart contained an Influenza and Pneumococcal Vaccine Consent and Tracking Form dated 10/24/23 showing telephone consent from the resident representative for that season, but there were no consent forms for 2024, 2025, or 2026. The record also did not contain documented evidence that the resident received or declined the influenza vaccine for those years. During the survey, the LPN confirmed that the EMR immunization record and paper consent matched the last consent obtained on 10/24/23. The RN/IPN stated that consent should be obtained and documented in the chart, but she could not locate documentation that the resident representative was contacted for consent for the influenza vaccine and stated there was no information showing the resident received the vaccine in 2024 or 2025. The facility policy stated that influenza vaccine is to be offered annually and that refusals must be documented in the resident's medical record.
Staffing Deficiencies and Delayed Call Bell Responses
Penalty
Summary
The facility failed to provide sufficient nursing staff and timely response to call bells, as evidenced by observations, interviews, and record reviews. During a resident council meeting, three residents reported that the 3-11 and 11-7 shifts were short-staffed, leading to delays in call bell responses. One resident mentioned waiting over 15 minutes for assistance, while another reported a delay of an hour. The facility's CASPER and PBJ reports indicated excessively low weekend staffing, which was confirmed by the surveyor's findings. Interviews with staff revealed that the facility did not meet the New Jersey mandated staffing ratios, particularly during the night shift. A Registered Nurse and Certified Nursing Aides (CNAs) reported being understaffed, with each CNA responsible for up to 19 residents, exceeding the state's requirement of 1 CNA per 14 residents during the night shift. The facility's grievance reports also documented complaints from residents about long wait times for call bell responses, further highlighting the staffing issues. The facility's policy on staffing and competency, as well as the Facility Assessment Tool, indicated that staffing plans should consider the needs of each unit and shift. However, the facility management acknowledged that they did not meet the staffing requirements, especially on weekends. The surveyor's review of the facility's staffing assignments confirmed the shortfall in staffing, particularly during the 11-7 shift, contributing to the delayed response to residents' needs.
Infection Control Deficiencies in Hand Hygiene and PPE Use
Penalty
Summary
The facility failed to adhere to proper hand hygiene and personal protective equipment (PPE) protocols, as observed during a survey. Two Licensed Practical Nurses (LPNs) did not perform hand hygiene after direct contact with residents and their environments during medication administration. One LPN was observed touching a resident and their immediate environment without washing hands before donning gloves. Another LPN failed to perform hand hygiene after administering medication and before exiting the resident's room. These actions were contrary to the facility's hand hygiene policy and CDC guidelines. Additionally, the facility did not follow appropriate infection control practices during medication and treatment pass observations. An LPN used the same vital signs equipment on two residents without disinfecting it between uses, and a Registered Nurse (RN) used disinfecting wipes that had been exposed to air for 15 minutes, failing to maintain the required contact time for effective disinfection. These practices were inconsistent with the facility's policies on equipment disinfection and the use of disinfecting wipes. The facility also failed to enforce isolation precautions for a resident on Transmission-Based Precautions. A Housekeeping staff member entered the room of a COVID-19 positive resident without wearing the required eye protection, despite signage indicating the need for full PPE. This oversight was acknowledged by the staff member and the facility's management, highlighting a lapse in adherence to the facility's PPE policy and CDC guidelines for preventing the spread of infection.
Inaccurate MDS Coding for Two Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for two residents, leading to deficiencies in the assessment of their care needs. For the first resident, the MDS was completed remotely by a per-diem worker who did not conduct an in-person interview. The resident was observed to have difficulty hearing, especially when masks were worn, and was noted to have some confusion. Despite these observations, the MDS inaccurately reflected adequate hearing and severely impaired cognition without a proper assessment. The resident's care plan indicated hearing impairment, but this was not accurately captured in the MDS, leading to a discrepancy between the resident's documented needs and the assessment. The second resident's MDS also contained inaccuracies. The resident was coded as sometimes understood in the MDS, yet the required interview for cognitive patterns was not attempted. The MDS Coordinator acknowledged that the interview should have been conducted according to the RAI Manual guidelines. Despite the resident's ability to be sometimes understood, the failure to attempt the interview resulted in an incomplete assessment of the resident's cognitive status. Both cases highlight a lack of adherence to the RAI Manual's guidelines for conducting resident assessments. The facility's reliance on remote workers for MDS completion without in-person interviews and the failure to attempt required interviews for residents who are sometimes understood contributed to the inaccurate coding of the MDS. These deficiencies were acknowledged by the facility management during discussions with the survey team, but no additional information or corrective actions were provided at the time.
Failure to Follow Physician Orders in Medication Administration
Penalty
Summary
The facility failed to adhere to physician orders during medication administration for a resident, as observed by a surveyor. A Registered Nurse (RN) administered a 500 mg tablet of Ascorbic Acid instead of the prescribed two 250 mg tablets due to the unavailability of the 250 mg tablets in the medication cart. The RN justified the substitution by stating that the total dose was the same, although the physician's order specifically required two 250 mg tablets. This action was contrary to the facility's policy, which mandates that medications be administered as prescribed. During the survey, the RN acknowledged the discrepancy and mentioned that she would check for the availability of the 250 mg tablets or contact the physician to amend the order. The Director of Nursing (DON) later confirmed that the appropriate action would have been to call the doctor. The facility's policy on administering medications, revised in April 2019, emphasizes the importance of administering medications safely, timely, and as prescribed, which was not followed in this instance.
Failure to Follow Resident's Care Plan During Allergic Reaction
Penalty
Summary
The facility failed to ensure that a resident's plan of care was followed during an acute change in condition, specifically when the resident experienced an allergic reaction. The resident, who had a history of allergies and was knowledgeable about their symptoms, reported to the nursing staff that they were experiencing an allergic reaction, characterized by shortness of breath, redness, and welts on their skin. Despite the resident's request to be sent to the hospital, the nurse on duty, RN#1, did not honor this request and instead administered Benadryl without obtaining a physician's order. The nurse attempted to contact the physician but did not receive a timely response. During this time, the resident self-administered an epinephrine pen from their personal belongings, which had a positive effect on their condition. However, the nurse proceeded to administer Benadryl without a physician's order and failed to notify the Director of Nursing (DON) or the resident's representative about the incident. The nurse documented the administration of the medication in the medical record but only obtained the physician's order for Benadryl hours later. The facility's investigation revealed that the nurse did not follow the appropriate procedures for medication administration and failed to respect the resident's right to be transferred to the hospital. The nurse's actions were not in line with the facility's policies on responding to changes in a resident's condition, administering medications, and respecting resident rights. The investigation concluded that there was no willful abuse or neglect, but the nurse's actions were not in accordance with professional standards of clinical practice.
Failure to Adjust Medication Schedule for Dialysis
Penalty
Summary
The facility failed to adjust a resident's medication schedule to accommodate their dialysis sessions, leading to a deficiency in care. The resident, who had end-stage renal disease and was dependent on dialysis, had a physician's order for dialysis every Monday, Wednesday, and Friday at 2:00 PM. Despite this schedule, the resident's medications were not adjusted accordingly, with several medications scheduled for administration at times when the resident was at dialysis. Observations and interviews revealed that the resident's medications were signed as administered at 4:30 PM and 5:00 PM, even though the resident was not present at the facility during these times due to dialysis. The Licensed Practical Nurse (LPN) and Registered Nurse Unit Manager (RN/UM) both acknowledged that medications should be scheduled around dialysis times and that any conflicts should be clarified with the physician. However, the Medication Administration Record (MAR) showed that medications were signed as administered at the scheduled times, despite the resident being at dialysis. The Director of Nursing (DON) confirmed that medications were administered when the resident returned from dialysis, but the facility's policy did not address adjusting medication times for dialysis sessions. The surveyor's review of the facility's policies revealed that they did not include guidance on accommodating medication schedules for dialysis, contributing to the deficiency. The Licensed Nursing Home Administrator (LNHA) acknowledged the issue and indicated that staff education and a quality assurance performance improvement (QAPI) initiative were being implemented.
Deficiencies in Medical Record Accuracy and Documentation
Penalty
Summary
The facility failed to maintain accurate medical records for two residents, leading to deficiencies in their care. For Resident #4, the surveyor found discrepancies in the medication records. The resident was prescribed Valacyclovir for a specific period in June 2024, but the medication continued to appear in the Physician/Practitioner Progress Notes without a corresponding physician's order in the electronic Medication Administration Record (eMAR) for the months following the completion of the prescription. This inconsistency was not addressed until the surveyor brought it to the attention of the facility management, who then clarified that the medication had been discontinued. For Resident #66, the surveyor observed that the Licensed Practical Nurse (LPN) was administering medication with special instructions for fluid restriction. However, there was no clear accountability or documentation in the eMAR regarding how much fluid the resident was allowed per shift, despite the special instructions indicating a fluid restriction of 1 liter per day. The Registered Nurse/Unit Manager and the LPN were unable to explain how the fluid restriction was being managed, and it was later revealed that the order for fluid restriction had been discontinued, yet the special instructions remained in the resident's profile. The facility's Charting and Documentation Policy requires that all services, progress, and changes in a resident's condition be accurately documented in the medical record to facilitate communication among the care team. However, the survey revealed that electronic entries were not being reviewed and updated as required, leading to incomplete and inaccurate documentation. The facility management did not dispute these findings during the exit conference with the survey team.
Failure to Complete SCSA for Resident Revoking Hospice Care
Penalty
Summary
The facility failed to complete a Significant Change in Status Assessment (SCSA) for a resident who revoked hospice care, as required by the CMS's RAI Manual. The resident, who was admitted with diagnoses including Parkinsonism, dementia, depression, and neuromuscular dysfunction of the bladder, was initially placed in hospice care for end-stage polycystic kidney disease. Despite the requirement to perform an SCSA within 14 days of the hospice care revocation, the facility did not complete this assessment. The MDS Coordinator acknowledged that the quarterly Minimum Data Set (qMDS) assessment conducted on January 13, 2024, should have been an SCSA. The deficiency was identified during a survey when the surveyor reviewed the resident's medical records and interviewed facility staff. The MDS Coordinator admitted the oversight, and the Licensed Nursing Home Administrator and Director of Nursing confirmed that the SCSA was not completed as required. The facility management did not dispute the findings during the exit conference with the survey team.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Cresskill
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Family Of Caring Healthcare At Tenafly, Llc | 0.9 mi | ★★★★★ | 1 | 0 |
| Actors Fund Home | 2.4 mi | ★★★★★ | 0 | 0 |
| Yonkers Gardens Center For Nursing And Rehab | 3.2 mi | ★★★★★ | 33 | 0 |
| Hudson Hill Center For Rehabilitation & Nursing | 3.2 mi | ★★★★★ | 9 | 0 |
| Hebrew Home For The Aged At Riverdale | 3.4 mi | ★★★★★ | 14 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.