Cedar Crest/Mountainview Gardens

In the surveyor’s words

From the most serious findings on record at Cedar Crest/Mountainview Gardens, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Sep 23, 2025

  Complaint #: NJ185754 Based on interviews, medical record review, and review of pertinent facility documents on 9/18/2025, it was determined that the facility failed to implement their abuse policy and procedure to ensure all residents were protected from abuse when a Dining Associate (DA #1) alleged a Certified Nursing Aide (CNA #1) physically abused a cognitively impaired resident (Resident #1) and did not immediately report the allegation and CNA #1 continued to provide resident care without a thorough investigation. This deficient practice was identified for 1 of 5 residents reviewed for abuse (Resident #1). On 4/19/2025 at approximately 4:45 PM, DA #1 alleged observing CNA #1 feed Resident #1 in the dining room. […]

• Actual harm, isolatedF689Jan 7, 2026

  Complaint # 2705112, 2704904 Based on interviews, medical record reviews, and review of other pertinent facility documentation on 1/7/26, it was determined that the facility failed to implement a two -person assistant when transferring Resident #1 from bed to wheelchair in accordance with the resident's care plan. This contributed to the resident exhibiting signs of pain by grimacing, after the inappropriate transfer of the resident from bed to wheelchair by their Certified Nursing Assistant (CNA#1). Further facility assessment of Resident #1 through X-ray report, revealed that the resident sustained right femoral neck fracture (hip fracture). […]

• Actual harm, isolatedF726Jul 25, 2024

  Based on interviews and review of electronic medical record, as well as review of pertinent facility documents on [DATE] and [DATE], the facility failed to ensure Certified Nursing Assistant (CNA#1) used a sit to stand lift and a two-person assist transfer in 1 (Resident #1) of 4 residents as determined necessary by the Resident's Holistic Care Plan (HCP). The failure to follow this intervention during the evening care transfer of Resident #1 by CNA #1 resulted in the Resident falling to the floor and became unresponsive subsequently requiring her/his immediate transfer to acute care hospital emergency room (ER) for further evaluation. In the ER, the Resident was found to have large bilateral subdural hematoma (a condition that indicates bleeding in the brain) and expired on [DATE]. […]

• No harm, potential for more than minimal, widespreadF812Sep 13, 2024

  Based on observation, interview, and review of facility policies, it was determined that the facility failed to maintain proper kitchen sanitation practices in a manner to prevent food borne illness. This deficient practice was observed and evidenced by the following: On 9/4/24 at 9:21 AM, the surveyor in the presence of the Campus Executive Chef (CEC) observed the following during the kitchen tour: 1. On the preparatory table, the surveyor observed the can opener with a caked on black colored debris. The CEC stated, they were unsure when the can opener was cleaned last, but the can opener would be cleaned immediately. 2. In the cooking area of the kitchen, the surveyor observed the standing dual oven with a sticky yellowish substance and dust like particles on top of the oven. […]

• No harm, potential for more than minimal, patternF658Sep 13, 2024

  Based on observation, interview, record review, and review of facility polices it was determined that the facility failed to: a.) carry out medication orders for a hospice resident and b.) clarify an oxygen order. This deficient practice was identified for 2 of 12 Residents (Resident #67 and #3) reviewed. The deficient practices were evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: The practice of nursing as a registered professional nurse is defined as diagnosing and treating human responses to actual and potential physical and emotional health problems, through such services as case-finding, health teaching, health counseling, and provision of care supportive to or… […]