Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
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 Cedar Crest/mountainview Gardens during CMS and state inspections, most recent first.
Call Bell Not Within Reach for Two Residents: Two residents with severely impaired cognition were observed with their soft-touch call bells placed out of reach, including one resident seated in a wheelchair and another resident in bed. Their care plans directed staff to provide a flat call bell for easy access, and an RN stated the call bell needs to be within reach for safety.
Hand hygiene was not followed correctly during meal service in the 2nd-floor dining room. An RN assisted one resident, then moved to another resident and back again without hand hygiene between residents, and stated hand hygiene was only needed before entering the dining room and after assisting all residents. A CNA was also observed washing hands incorrectly multiple times, including rinsing without soap or lathering and lathering for only a few seconds instead of the required 20 seconds.
A resident with Parkinson’s disease, Alzheimer’s disease, gait abnormalities, muscle weakness, poor cognition, and osteopenic bones had a care plan and clinical documentation requiring total assist of two staff and use of a sit-to-stand lift for transfers. Despite this, a CNA independently performed a stand-pivot transfer from bed to wheelchair. After this transfer, the resident showed nonverbal signs of pain, and imaging later confirmed an acute right femoral neck fracture. Staff interviews indicated that care plans and care cards with transfer status were accessible in the resident’s room and that CNAs were expected to review them before care, while the DON confirmed that the CNA did not follow the prescribed two-person sit-to-stand transfer method.
A DA observed a CNA allegedly physically abuse a cognitively impaired resident during feeding, but did not immediately report the incident. The CNA continued to work for three shifts with access to the resident and others before the allegation was reported to administration, contrary to facility policy requiring immediate reporting and removal of implicated staff. The resident had severe cognitive impairment and was fully dependent on staff for eating.
A resident with a signed DNR order and POLST experienced a cardiac arrest, during which an LPN initiated chest compressions without first verifying the resident's code status. Both the LPN and RN later confirmed that the facility's policy, which requires checking code status before providing life-sustaining treatment, was not followed. The DON also acknowledged that staff are expected to verify code status prior to treatment, and that this did not occur in this incident.
A resident with multiple medical conditions was sent to the ER for tachycardia, nausea, and weakness, but the required New Jersey Universal Transfer Form was not fully completed prior to transfer. The DON confirmed the form should have been entirely filled out by the nurse, in accordance with facility policy.
A survey revealed that the facility failed to maintain proper kitchen sanitation practices, with issues such as a dirty can opener, unclean ovens, and a fryer with food crumbs. The facility's policies require regular cleaning and sanitizing of food contact surfaces and equipment, but observations indicated non-compliance. The CEC and Chef #1 were unable to confirm when the equipment was last cleaned.
The facility failed to administer prescribed hospice medications for a resident with chronic pain and anxiety, as the orders for Morphine and Ativan were not carried out despite being initialed by a nurse practitioner. Additionally, the facility did not clarify an ambiguous oxygen order for another resident, leading to potential inconsistencies in care. These deficiencies highlight lapses in following facility policies on medication administration and order clarification.
A facility failed to accurately code the MDS for a resident's discharge, marking it as unplanned when it was actually planned to an AL facility. This discrepancy was identified during a survey, and the MDS Coordinator confirmed the error. The facility's policy requires accurate resident assessments, which was not followed in this case.
A CNA on the Terrace Unit failed to follow proper hand hygiene and PPE protocols, as observed by a surveyor. The CNA did not remove gloves or sanitize hands between resident care activities, despite residents being on Enhanced Barrier Precautions (EBP). The CNA admitted to not being trained on EBP, and the facility's management acknowledged the lapse in adherence to infection control measures.
A CNA failed to follow a resident's care plan, which required a two-person assist and a sit-to-stand lift for transfers. Instead, the CNA attempted a stand-pivot transfer alone, resulting in both the CNA and the resident falling. The resident, who had multiple health conditions, became unresponsive and was later diagnosed with subdural hematomas, leading to her death.
Call Bell Not Kept Within Residents' Reach
Penalty
Summary
The facility failed to keep the call bell soft-touch pad within reach for two residents reviewed for accommodation of needs. Resident #57 was observed in the room seated in a wheelchair in front of the sink with the call bell soft-touch pad on the bedside table and not within reach on 01/22/2026 and again on 01/23/26. The record showed the resident was admitted with diagnoses including Alzheimer's Disease, diabetes mellitus, and chronic kidney disease, and the Quarterly MDS dated 10/27/25 indicated severely impaired cognitive skills for daily decision-making, dependence on staff for activities of daily living care, and receipt of hospice services. The resident's Holistic Care Plan for Falls directed staff to provide a flat sensory soft-touch call bell for easy access and to encourage use of it. Resident #112 was observed in the room in bed watching television with the call bell soft-touch pad hanging off the bedside railing and not within reach on 01/22/26, and again on 01/23/26 with the call bell hanging off the bed and not within reach. The record showed the resident was admitted with diagnoses including Alzheimer's Disease, contracture of the right hand, and anxiety, and the Quarterly MDS indicated severely impaired cognitive skills for daily decision-making, moderate assistance needed for activities of daily living care, and impairments of the upper extremities. The resident's Holistic Care Plan for Falls directed staff to provide a flat call bell. During the survey, the 3rd floor Unit Manager/RN stated the call bell needs to be within reach of the resident for safety.
Hand Hygiene Not Followed During Meal Service
Penalty
Summary
The facility failed to follow appropriate hand hygiene practices during meal service in the 2nd-floor dining room. During observation, an RN assisted one resident with feeding and then went to assist another resident and returned to feed the first resident again without any observed hand hygiene between residents. The RN later stated that hand hygiene was only needed before entering the dining room and after assisting all residents, and that hand hygiene before and after assisting with meals was not important. The RN's hand hygiene competency reflected that hand hygiene should be performed immediately before, between, and after physical contact with a resident and anytime food is handled. A CNA was also observed assisting residents with meal service and performing hand hygiene incorrectly on multiple occasions. After assisting one resident, the CNA wet her hands and placed them under running water without applying soap or lathering outside the stream of water, then later applied soap and immediately placed her hands under running water without lathering for 20 seconds outside the stream, and on another occasion lathered for only 5 seconds before rinsing. When questioned, the CNA stated she had been taught to lather her hands under running water for 20 seconds, then acknowledged she had been mistaken and confirmed she should have washed her hands in accordance with facility policy. The CNA's competency record reflected instruction to scrub all surfaces of the hands for at least 20 seconds before rinsing.
Failure to Follow Two-Person Sit-to-Stand Transfer Care Plan Resulting in Hip Fracture
Penalty
Summary
The deficiency involves the facility’s failure to follow a resident’s care plan requiring a two-person assist with a sit-to-stand lift for transfers from bed to wheelchair. The resident had multiple diagnoses including Parkinson’s disease, Alzheimer’s disease, abnormalities of gait and mobility, muscle weakness, lack of coordination, and osteopenic bone structure. The resident’s MDS showed poor cognition, and clinical documentation on multiple dates indicated that the resident required total assistance of two persons for transfers using a sit-to-stand lift. The resident’s care plan, revised on 10/28/25, specifically documented the need for a sit-to-stand lift with assistance from two staff members for transfers. On 12/24/25, the resident exhibited nonverbal signs of pain, such as grimacing, following a transfer from bed to wheelchair. An x-ray of the bilateral hips and pelvis was ordered and later revealed an acute right femoral neck fracture with mild displacement, while the pelvis and left hip appeared intact and bony structures were osteopenic. Subsequent clinical notes documented the fracture and the resident’s transfer to the hospital for further evaluation and treatment. The facility’s internal investigation, as reported in the Facility Reportable Event submitted to the Department of Health, confirmed that the CNA assigned to the resident on 12/24/25 had transferred the resident independently using a stand-pivot technique. Interviews conducted by the surveyor showed that CNAs and nursing staff were expected to follow the resident’s care plan and care card, which were kept in binders in each resident’s bedroom closet. CNA staff and an LPN stated that transfer status and ADL needs were located on the care plans and that CNAs were expected to check these before providing care. The DON confirmed that the investigation determined there had been no fall and that the CNA did not follow the resident’s care plan, which required a sit-to-stand lift with two staff for transfers. The CNA position description and the facility’s care/service plan policy both required implementation of individualized care plans and documentation and communication of updates to CNAs, underscoring that the resident’s prescribed transfer method was not followed at the time of the incident.
Failure to Immediately Report and Respond to Alleged Staff-to-Resident Abuse
Penalty
Summary
The facility failed to implement its abuse prevention policy and procedure when a Dining Associate (DA) witnessed a Certified Nursing Aide (CNA) allegedly physically abusing a cognitively impaired resident during a meal. The DA observed the resident expressing that the soup was too hot and attempting to resist, while the CNA pushed the resident's hands down, grabbed their arm, and manipulated it to make a gripping motion. Despite witnessing this, the DA did not immediately report the incident, waiting three days before notifying administration, during which time the CNA continued to work and had access to the resident and others. The resident involved had significant medical conditions, including Alzheimer's disease, chronic kidney disease, and diabetes, and was assessed as having severely impaired cognitive skills with total dependence on staff for eating. The care plan for the resident did not include information that the resident would say food was too hot to indicate fullness, which was relevant to the incident. The CNA stated that the resident often said food was hot as a way to communicate being done with eating, and that she would hold the resident's hand to comfort them during meals. The facility's policies required immediate reporting of suspected abuse and removal of implicated staff from resident care pending investigation. However, the delay in reporting by the DA and the continued assignment of the CNA to resident care for three shifts after the alleged incident meant that the facility did not protect the resident or others from potential abuse as required. This failure resulted in an Immediate Jeopardy situation, as the CNA was not suspended until the allegation was finally reported.
Removal Plan
- Resident #1 received a body and pain assessment after DA #1 reported the allegation of abuse, with no injuries or pain noted; and emotional support and reassurance were provided.
- CNA #1 was suspended and educated on the facility's abuse policy before their next scheduled shift.
- DA #1 and CNA #1 were educated on the facility's abuse policy.
- The Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), Assistant Licensed Nursing Home Administrator (ALNHA), Assistant Director of Nursing (ADON), or designee conducted education with all current staff in all departments on the facility's abuse prevention policy to include immediately reporting all allegations of abuse.
- The LNHA or designee reviewed the last thirty days of grievances/concerns to identify abuse concerns.
- The Social Worker (SW) interviewed residents with Brief Interview for Mental Status (BIMS) scores of 8 or above (moderately impaired to intact cognition) to identify abuse, neglect or care related concerns.
- A licensed nurse completed a physical assessment/observation of all residents with BIMS scores of 7 or below (severe cognitive impairment).
Failure to Honor Resident's DNR Status During Cardiac Arrest
Penalty
Summary
The facility failed to honor a resident's Do Not Resuscitate (DNR) status during a cardiac arrest event. The resident, who had diagnoses including dementia, hypertension, and muscle weakness, had a signed DNR order and a Practitioner Orders for Life-Sustaining Treatment (POLST) in their chart. When the resident experienced a witnessed cardiac arrest, chest compressions were initiated by an LPN without first verifying the resident's code status. The LPN later acknowledged not checking the code status prior to starting chest compressions and stated that the facility's policy was not followed. Interviews with the LPN, RN, and Director of Nursing confirmed that the expectation and policy were to verify a resident's code status before initiating any life-sustaining treatment. The RN, who was the primary nurse, also stated that the code status was not confirmed before chest compressions began and that the facility's policy was not followed. The Director of Nursing reiterated that staff are expected to check the code status, which is located at the front of the resident's chart, before providing treatment. Facility documentation and staff interviews consistently indicated that the resident's wishes, as documented in the DNR order and POLST, were not followed during the emergency event.
Incomplete Universal Transfer Form During Resident Hospital Transfer
Penalty
Summary
A deficiency was identified when a resident, admitted with diagnoses including dementia, hypertension, and muscle weakness, was transferred to the emergency room for tachycardia, nausea, and weakness. Upon review, the resident's medical record revealed that the New Jersey Universal Transfer Form (NJUTF) for this transfer was not filled out completely. The Director of Nursing confirmed during an interview that the transfer form should have been entirely completed by the nurse prior to the resident's transfer, and acknowledged that this was not done. Facility policy requires that the Universal Transfer Form be fully completed and accompany each resident who is transferred or discharged.
Kitchen Sanitation Deficiencies Observed
Penalty
Summary
The facility failed to maintain proper kitchen sanitation practices, as observed during a survey on September 4, 2024. The surveyor, accompanied by the Campus Executive Chef (CEC), noted several sanitation issues in the kitchen. A can opener on the preparatory table was found with caked-on black debris, and the CEC was unsure of the last cleaning date. In the cooking area, a standing dual oven had a sticky yellowish substance and dust-like particles on top, with the CEC again unable to confirm the last cleaning. Additionally, the deep fryer contained multiple food crumbs, despite not being used that day, and Chef #1 could not explain why it was not cleaned after its last use. The standing combination oven also had a grease-like substance on top, with the CEC unable to specify the last cleaning date. On September 5, 2024, the Director of Nursing (DON) provided the surveyor with facility policies on cleaning and sanitizing food contact surfaces and major cooking equipment, both revised in January 2024. These policies outlined that all food contact surfaces should be cleaned and sanitized at the beginning of each shift, prior to use, at the end of use, and between tasks. Major cooking equipment should be thoroughly cleaned and sanitized after each use. However, the observations made during the survey indicated non-compliance with these policies. During a meeting on September 6, 2024, with the Assistant Licensed Nurse Home Administrator (ALNHA) and DON, no comments were provided regarding the concerns raised.
Failure to Administer Hospice Medications and Clarify Oxygen Order
Penalty
Summary
The facility failed to carry out medication orders for a hospice resident, Resident #67, who was admitted with diagnoses including Parkinson's disease, peripheral autonomic neuropathy, and chronic pain. The resident was on hospice care, and a hospice nurse had recommended medications including Morphine and Ativan for pain and anxiety management. These recommendations were initialed by the nurse practitioner but were not entered into the physician orders or administered. Despite multiple reviews by nursing staff, the omission was not identified or rectified, leaving the resident without the prescribed pain and anxiety management. Additionally, the facility failed to clarify an oxygen order for Resident #3, who was admitted with conditions such as hyperlipidemia, congestive heart failure, emphysema, and hypertension. The resident was observed receiving oxygen at 2.5 liters per minute, but the physician's order was ambiguous, stating 2-3 liters per minute. The order was not clarified with the physician, and the resident's care plan did not specify the exact oxygen flow rate, leading to potential inconsistencies in care. The facility's policies on hospice program and physician orders were not adhered to, as evidenced by the failure to implement the hospice medication recommendations and the lack of clarification of the oxygen order. The surveyor's interviews with nursing staff and management revealed a lack of awareness and follow-through on these critical care aspects, contributing to the deficiencies identified during the survey.
Inaccurate MDS Coding for Resident Discharge
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for one resident, leading to a deficiency. The issue was identified during a surveyor's review of the resident's records. The resident, who was discharged from the facility, had their discharge type incorrectly coded as unplanned on the Discharge Return Anticipated MDS dated 6/27/24. However, progress notes from 6/18/24 indicated that the discharge was planned to an Assisted Living (AL) facility. The MDS Coordinator acknowledged that the discharge should have been coded as planned. This discrepancy was brought to the attention of the Director of Nursing and the Administrator during the surveyor's interview on 9/9/24. The facility's policy mandates that resident assessments be completed accurately, which was not adhered to in this instance.
Inadequate Hand Hygiene and PPE Use by CNA
Penalty
Summary
The facility failed to adhere to proper infection prevention and control protocols, specifically regarding hand hygiene and the use of personal protective equipment (PPE). A Certified Nursing Assistant (CNA) on the Terrace Unit was observed exiting a resident's room, who was under Enhanced Barrier Precautions (EBP), without removing gloves or performing hand hygiene. The CNA then entered another resident's room and provided care without changing gloves or sanitizing hands. This action was contrary to the facility's policy and CDC guidelines, which require hand hygiene before and after resident contact, and between different care activities. Further observations revealed that the CNA continued to neglect hand hygiene protocols during meal service, as she delivered a meal tray to a resident's room without sanitizing her hands. The CNA admitted to not being in-serviced on EBP and was unaware of the requirement to perform hand hygiene when entering and exiting rooms of residents on EBP. The Acting Unit Manager and the Director of Nursing confirmed that the facility's policy mandates hand hygiene before entering and exiting rooms, and that staff were supposed to be trained on these protocols. However, the CNA's actions indicated a lapse in adherence to these infection control measures.
Failure to Follow Care Plan Leads to Resident's Fall and Death
Penalty
Summary
The facility failed to ensure that a Certified Nursing Assistant (CNA) followed the Resident's Holistic Care Plan (HCP) for transferring a resident, which resulted in a serious incident. The resident, who had multiple diagnoses including Hydrocephalus, Alzheimer's Disease, and Dementia, required extensive assistance with two-person physical support and a sit-to-stand lift for transfers. However, during an evening care transfer, the CNA attempted to transfer the resident using a stand-pivot technique without additional staff assistance, contrary to the care plan. During the transfer, the resident began to shake and lost balance, leading the CNA to attempt to lower the resident to the floor. Unfortunately, both the CNA and the resident fell, with the resident landing on her back and becoming verbally unresponsive. The resident was subsequently transferred to an acute care hospital, where she was diagnosed with large bilateral subdural hematomas and later expired. The investigation revealed that the CNA did not consult the assignment sheet or the resident's care plan before attempting the transfer. The CNA admitted to not reading or looking at the assignment sheet, which contained the necessary information about the resident's care needs. The facility's Director of Nursing and Nursing Home Administrator confirmed that the incident occurred because the CNA did not follow the outlined plan of care.
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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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Nursing homes near Pompton Plains
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Health Center At Bloomingdale | 2.2 mi | ★★★★★ | 16 | 0 |
| Phoenix Center For Rehabilitation And Pediatrics | 2.8 mi | ★★★★★ | 1 | 0 |
| Complete Care At Wayne Hills Rehab & Resp Center | 2.9 mi | ★★★★★ | 18 | 0 |
| Llanfair House Care & Rehabilitation Center | 3 mi | ★★★★★ | 0 | 0 |
| Arbor Ridge Rehabilitation And Healthcare Center | 3 mi | ★★★★★ | 0 | 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.