Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Crest Haven Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with multiple complex medical conditions and moderately impaired cognition repeatedly refused ordered wound care treatments and facility-prepared meals, preferring home-cooked food. Despite these documented refusals and communication from the resident's spouse, the ICCP did not address the resident's non-compliance or preferences, in violation of facility policy.
A resident with dementia and multiple medical conditions was admitted to hospice care with new physician orders for DNR and DNI, but the care plan was not updated and continued to reflect Full Code status. Staff interviews confirmed that the care plan should have been revised immediately to align with the new orders, but this was not done.
The facility did not consistently meet the required CNA-to-resident ratios for the day shift, as mandated by New Jersey law. Staffing reports and interviews confirmed that on multiple occasions, the number of CNAs scheduled was below the minimum required, despite the facility's awareness of the regulations and stated efforts to comply.
The facility did not meet the required nurse staffing hours for one day during a two-week period, providing 1.5 hours less than mandated based on resident count and acuity. Despite scheduling efforts, including bonuses and agency staff, actual nursing hours fell short of the minimum required to meet resident care needs.
The facility did not have an Assistant Director of Nursing (ADON) who is a registered nurse, as required for facilities with 150 or more licensed beds. The LNHA confirmed the facility was licensed for 180 beds and acknowledged the ADON position was vacant following a resignation.
Crest Haven Nursing and Rehabilitation Center did not ensure a registered nurse (RN) was on duty at all times as required for facilities with more than 150 licensed beds, with staffing records showing that an RN was absent for a significant number of shifts over several reviewed weeks. Facility leadership demonstrated a misunderstanding of the regulatory requirements, and the facility's own policy was not followed.
A resident with depression and suicidal ideation was recommended for 1:1 supervision by a PNP, but an LPN failed to communicate the full extent of the risk to the primary physician, resulting in continued 15-minute checks instead of constant observation. The resident subsequently attempted self-harm and required emergency intervention. Staff interviews confirmed that the recommendation for increased supervision was not properly relayed, and the facility's policy for physician notification was not followed.
Failure to Individualize Care Plan for Resident Refusals and Preferences
Penalty
Summary
The facility failed to develop and implement an individualized comprehensive care plan (ICCP) for a resident who was non-compliant with receiving ordered treatments and meals prepared by the facility. The resident had significant medical conditions, including a stage 4 pressure ulcer, malignant neoplasm of the rectum, and a right fibula fracture, and was assessed as having moderately impaired cognition. Despite documented refusals of wound care treatments and prescribed medications on multiple occasions, as well as repeated refusals of facility-prepared meals in favor of home-cooked food, the care plan did not address these refusals or the resident's preferences. Documentation in the medical record, treatment administration record, and nursing progress notes confirmed the resident's pattern of refusing both treatments and meals. The resident's spouse also communicated the resident's preference for home-cooked meals to nursing staff. However, the comprehensive care plan lacked any focus or interventions related to the resident's refusals or meal preferences, contrary to the facility's own policy requiring incorporation of personal and cultural preferences and documentation of services not provided due to resident choice.
Failure to Update Care Plan After Change in Code Status
Penalty
Summary
The facility failed to revise the individualized comprehensive care plan for a resident following a change in code status. The resident, who had diagnoses including dementia, anxiety disorder, and protein-calorie malnutrition, was admitted with significant cognitive impairment and required maximum assistance for most activities of daily living. Despite a physician's order changing the resident's code status to Do Not Resuscitate (DNR) and Do Not Intubate (DNI) and the resident's admission to hospice care, the care plan continued to reflect a status of Full Code. The care plan still included interventions such as performing CPR and reviewing code status quarterly, which were inconsistent with the new orders. Interviews with facility staff, including a CNA, LPN, Unit Manager, and Director of Nursing, confirmed that the care plan should have been updated immediately to reflect the change in code status. The Unit Manager acknowledged responsibility for updating the care plan, and the Director of Nursing confirmed that the care plan did not reflect the new DNR/DNI orders as required. Review of facility policy indicated that care plans must be comprehensive, person-centered, and updated to meet residents' needs, but this was not followed in this instance.
Failure to Maintain Minimum CNA Staffing Ratios
Penalty
Summary
The facility failed to maintain the required minimum direct care staff to resident ratios as mandated by the state of New Jersey. This deficiency was identified through a review of staffing reports and interviews, revealing that on multiple occasions, the number of Certified Nurse Aides (CNAs) scheduled for the day shift did not meet the statutory requirement of one CNA for every eight residents. Specific instances were documented where the facility was short by one or more CNAs on various day shifts, with similar deficiencies noted for the evening shift on at least one occasion. The surveyor's review of facility documentation, including the "Nursing Staffing Report" and the facility's "Sufficient Staffing Policy," confirmed that the facility was aware of the minimum staffing requirements. Despite this, the facility's own records showed repeated non-compliance across several weeks, with as many as six out of seven day shifts in some weeks falling below the required CNA-to-resident ratio. The Scheduling Coordinator and the Licensed Nursing Home Administrator both acknowledged familiarity with the staffing requirements and reported efforts to meet them, such as using agency staff and offering bonuses, but the documented staffing levels did not consistently meet the mandated ratios. No specific residents or patient medical histories were detailed in the report, and the deficiency was identified based on staffing numbers and scheduling practices rather than individual resident outcomes. The findings were based on a combination of interviews with facility staff and a review of staffing schedules over multiple weeks, demonstrating a pattern of insufficient CNA staffing during the day shift.
Plan Of Correction
The facility actively seeks to hire CNAs, that all shifts are scheduled to comply with ratios, that any callouts or no-shows result in calls being made by the Staffing Coordinator or the shift Supervisor to fill the shift. The facility has documented evidence to reflect recruitment and retention efforts in its relentless attempts to comply with the staffing ratios. All residents have the potential to be affected. Staffing Coordinator was re-educated by the Administrator on current staffing regulation and shift ratios. Recruitment and retention efforts continue to include: a. Daily staffing meetings and weekly Regional Labor Management reviews b. Training mentor program to support retention c. Employee Enrichment committee in place to improve and maintain staff morale d. Recruitment bonus and sign-on bonuses offered e. Competitive wage analysis DON/Staffing Coordinator/Administrator or designee will monitor and review staffing daily for 1 week, weekly for 3 weeks, and monthly for 3 months. Results will be presented to the Quality Assurance and Performance Improvement (QAPI) team monthly for continued review and recommendations until substantial compliance is maintained.
Deficiency in Mandatory Nurse Staffing Hours
Penalty
Summary
The facility failed to meet the mandatory nurse staffing requirements as outlined in N.J.A.C. 8:39-25.2(b)(1)&(2) for 1 out of 14 days during the review period. Specifically, on one day, the actual nursing staff hours provided were 208, which was 1.5 hours less than the required 209.5 hours based on the total number of residents and the acuity-based care hours needed for services such as wound care, tube feedings, oxygen therapy, tracheostomy, intravenous therapy, use of respirator, and advanced neuromuscular/orthopedic care. The deficiency was identified through a review of the Nurse Staffing Reports for the specified two-week period. During an interview, the Licensed Nursing Home Administrator (LNHA) acknowledged awareness of the minimum staffing ratio requirements and stated that the facility scheduled staff to meet those needs, utilizing bonuses and agency staff as needed. The facility's "Sufficient Staffing" policy, revised prior to the deficiency, required sufficient nursing staff with appropriate competencies to meet resident care needs on a 24-hour basis, including the designation of a registered nurse responsible for overseeing nursing activities on each shift. Despite these policies and efforts, the facility did not meet the required staffing hours on the identified day.
Plan Of Correction
The facility cannot retroactively correct the deficient practice. However, the facility seeks to schedule staff based on the required staffing level to comply with the State of NJ staffing requirements. All residents have the potential to be affected. The Administrator initiated an in-service with the Director of Nursing (DON) and Staffing Coordinator on ensuring that the required staffing levels are provided and also reviewed the Sufficient Staffing policy. The DON and Staffing Coordinator will complete daily staffing sheets to ensure that the facility is meeting the required staffing levels per regulations. The DON, Staffing Coordinator, Administrator and or designee will monitor and review the daily Staffing Acuity Work Sheets weekly x 4 weeks and then monthly x 3 months to ensure that the daily required staffing levels were met. The results will be presented to, will be reported, reviewed by the DON, Staffing Coordinator and or designee and submitted to the monthly Quality Assurance and Performance Improvement Committee (QAPI) for three (3) months in order to determine if further interventions are needed.
Failure to Maintain Required ADON Staffing
Penalty
Summary
The facility failed to ensure compliance with the mandatory nurse staffing requirement by not having an Assistant Director of Nursing (ADON) who is a registered professional nurse (RN) in place, as required for facilities with 150 licensed beds or more. During the entrance conference, the Licensed Nursing Home Administrator (LNHA) confirmed that the facility was licensed for 180 beds and had a current resident census of 74. Upon further inquiry, the LNHA acknowledged that an ADON was required due to the facility's bed count, but stated that the previous ADON had resigned and the position was currently vacant. This deficiency was identified through interviews and direct confirmation from facility leadership.
Plan Of Correction
The facility cannot retroactively correct the deficient practice. However, the facility has designated an interim RN ADON while still actively seeking to hire a Registered Nurse (RN) Assistant Director of Nursing (ADON). All residents have the potential to be affected. Staffing Coordinator and Director of Nursing were educated by the Administrator on current staffing regulation and RN, ADON coverage for buildings licensed for 150 or more beds. DON/Staffing Coordinator/Administrator or designee will monitor and review staffing daily for 1 week, weekly for 3 weeks, and monthly for 3 months to ensure that an ADON is staffed. All findings from the audits will be reported, reviewed by the DON or designee, and submitted to the monthly Quality Assurance and Performance Improvement Committee (QAPI) for three (3) months in order to determine if further interventions are needed.
Failure to Maintain Required RN Staffing Levels
Penalty
Summary
Crest Haven Nursing and Rehabilitation Center failed to ensure that a registered professional nurse (RN) was on duty at all times, as required for facilities with more than 150 licensed beds. During a review of staffing records for multiple weeks, it was found that the facility did not have an RN on duty for a significant number of shifts—147 out of 231 shifts reviewed. Specific weekly breakdowns showed that, in several weeks, the facility lacked RN coverage for 10 to 14 out of 21 shifts per week. The Licensed Nursing Home Administrator (LNHA) confirmed the facility had 180 licensed beds and a resident census of 74 at the time of the survey. The facility's own policy stated that a RN should oversee total nursing activities on each tour of duty every day of the week. Interviews with facility leadership revealed a misunderstanding of the regulatory requirement, with the LNHA stating that an RN was only required for eight hours in a 24-hour period for facilities with more than 120 beds, which does not align with the cited regulation. The deficiency was identified through both interviews and review of the facility's nurse staffing reports (AAS-11), which documented the lack of RN coverage during the reviewed periods.
Plan Of Correction
The facility cannot retroactively correct the deficient practice. However, the facility actively seeks to hire Registered Nurses (RNs), ensuring that all shifts are scheduled to comply with the requirement. The facility has documented evidence to reflect recruitment and retention efforts in its relentless attempts to comply with the staffing ratios. All residents have the potential to be affected by this deficient practice. Staffings Coordinator and Director of Nursing were educated by the Administrator on current staffing regulations and RN coverage for buildings licensed for 150 or more beds. Recruitment and retention efforts include: a. Daily staffing meetings and weekly Regional Labor Management reviews b. Training mentor program to support retention c. Employee Enrichment committee d. Collaboration with nursing schools The DON/Staffing Coordinator/Administrator or designee will monitor and review staffing daily for 1 week, weekly for 3 months. Results will be presented to the Quality Assurance and Performance Improvement (QAPI) Committee monthly for continued review and recommendations until substantial compliance is maintained.
Failure to Notify Physician of Critical Change in Resident's Status
Penalty
Summary
A deficiency occurred when facility staff failed to properly notify a resident's primary physician of a critical recommendation made by the psychiatric nurse practitioner (PNP). The resident, who had diagnoses including Parkinson's Disease, depression, and alcohol use, was assessed as having intact cognition but moderate depression. The PNP, after a video-conference evaluation, recommended 1:1 supervision for the resident due to the resident's inability to contract for safety and ongoing suicidal ideation. However, the unit manager (UM/LPN) who communicated with the primary physician did not relay the crucial information that the resident had not contracted for safety, instead reporting that the resident was doing well on every 15-minute checks and omitting the PNP's recommendation for increased supervision. As a result of this incomplete communication, the primary physician approved the continuation of 15-minute checks rather than implementing the recommended 1:1 supervision. The resident continued to be monitored every 15 minutes, rather than under constant observation as advised. During this period, the resident was found by a visitor in a bathroom with a plastic bag over their head and strings tightly gripped around their neck, having attempted self-harm. Emergency services were called, and the resident was transported to an acute care hospital for crisis evaluation. Interviews with facility staff confirmed that the PNP's recommendation for 1:1 supervision was not fully communicated to the primary physician, and that the staff involved were aware the resident had not contracted for safety. The director of nursing and the licensed nursing home administrator also acknowledged awareness of the resident's ongoing risk but did not implement the recommended level of supervision. The facility's policy required clear and complete communication of significant changes in a resident's condition to the physician, which was not followed in this case.
Removal Plan
- Individual education for the involved Unit Manager
- Training for licensed nursing staff involved in receiving recommendations
- Training on notifications of changes in residents' status
- Revision of physician notification policy
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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 Cape May Court House
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Complete Care At Court House, Llc | 1.2 mi | ★★★★★ | 1 | 0 |
| Fountain Springs At Cape May Nursing & Rehab Cente | 4.6 mi | ★★★★★ | 0 | 0 |
| Autumn Lake Healthcare At Oceanview | 8.7 mi | ★★★★★ | 1 | 0 |
| North Cape Center | 10.8 mi | ★★★★★ | 0 | 0 |
| Pelican Pointe Post Acute Nursing & Rehabilitation | 11.2 mi | ★★★★★ | 0 | 0 |
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