Cranbury Center

Inspectors wroteBased on observation, interviews, review of medical records, and review of other pertinent facility documents on 05/28/2026, it was determined that the facility failed to maintain an environment free from the use of physical restraint for Resident #2. This deficient practice was identified for 1 of 6 residents (Resident #2) reviewed for restraint. During the survey, a tour was conducted by the surveyor, there was no restrictive device noted for any resident. On 05/23/2026, during the 7:00 AM-3:00 PM shift, the Registered Nurse (RN#1) who was assigned to Resident #2 stated the resident was experiencing respiratory distress. RN#1 administered a respiratory treatment by nebulizer mask. RN#1 stated during the treatment Resident #2 became combative and pulled off the mask from their face. [...]

Inspectors wroteBased on interview and review of pertinent facility documents, it was determined that the facility failed to ensure the code status for a resident (Resident # 61) was accurately documented in the electronic medical record (EMR) that correctly identified their wishes in the event of a medical emergency. This deficient practice was identified for 1 out of 37 residents (Resident # 61). Resident # 61 wished to be a Do Not Resuscitate (DNR; do not perform cardiopulmonary resuscitation (CPR) if a person's heart stops or they cease breathing). A review of the resident's EMR revealed that Resident # 61's code status was documented as DNR/Full Code (all resuscitation procedures will be provided when a person stops breathing or their heart stops beating). [...]

Inspectors wroteBased on observation, interviews, and facility policy review, the facility failed to ensure areas in the kitchen remained sanitary including sanitation buckets remaining at the correct Parts Per Million (PPM) level, the outside of the ice machine was cleaned, dry storage was properly labeled and dated, broken equipment was not used and covers for the steam table were clean when in use. This failure had the potential to affect the spread of food borne illness for 100 of 101 total sampled residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure that four residents (R70, R11, R77, and R20) out of 37 residents sampled had a Minimum Data Set (MDS) that accurately reflected their Preadmission Screening and Resident Review (PASRR) Level II status. This had the potential to affect all residents who qualified for a PASRR Level II.

Inspectors wroteBased on interview, record review, review of facility reported incident (FRI), and review of the facility policy, the facility failed to ensure one (Resident (R) 46) of four residents reviewed for abuse out of a total sample of 37 residents was free from abuse. This had the potential for an injury to the resident.

Inspectors wroteBased on record reviews, interviews, and facility policy review, the facility failed to identify targeted behaviors, conduct behavior tracking and monitor the side effects of antipsychotic medications for two of five sampled residents (Resident (R) 80 and R6) reviewed for unnecessary medications out of a total sample of 37 residents. These failures placed the residents at risk for not obtaining the intended therapeutic goal of the antipsychotic medication and the potential for serious adverse effects from the antipsychotic medications.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to report an allegation of verbal abuse within two hours for two of three residents (Resident (R) 80 and R46) reviewed for abuse out of a total of 37 residents. his had the potential for continued abuse of the residents.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to thoroughly investigate allegations of verbal and physical abuse for two residents (Resident (R) 46 and R85) out of five residents reviewed for abuse out of a total sample of 37 residents. This had the potential for continued abuse of the residents.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to ensure one resident (Resident (R) 5) of 37 residents reviewed was invited to their care plan conference. The facility further failed to hold a care plan conference for R119. This had to potential to cause the residents to be not informed regarding their care.

Inspectors wroteBased on observations, interviews, and facility policy review, the facility failed to ensure a homelike environment when staff delivered the lunch meal on a tray from the cart to the table and did not remove the food from the tray in the dining room for 16 of 55 residents that resided on Unit C (Residents (R) 16, R23, R39, R47, R49, R54, R56, R69, R70, R75, R80, R86, R90, R110, R113 and R123. This failure had the potential to result in an institutional dining experience.

Inspectors wroteBased upon observation, interview, and facility policy review the facility failed to allow cooking vessels to completely air dry before being placed for storage in one of one kitchen. This failure has the potential to create an environment that would enable bacteria growth between the vessels which could cause illness among 127 of 128 residents.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to maintain the residents' dignity when staff stood while assisting residents to eat in the dining room for one of 17 residents (Resident (R) 16) reviewed for meal assistance of 34 sampled residents. This failure had the potential to result in an undignified dining experience.

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to follow a physician's order for a right-hand splint device for one of one resident (Resident (R) 74) reviewed for range of motion of 34 sample residents. This failure could potentially cause worsening contractures and a decline in range of motion.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to follow infection control and prevention guidelines to prevent cross-contamination when they did not follow Enhanced Barrier Precautions (EBP) while performing catheter care for one of one resident (Resident (R) 103) reviewed for catheters of 34 sampled residents. This failure had the potential to spread multidrug resistant organisms (MDROs) to the residents.

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to maintain readily accessible and systematically organized medical records. This deficient practice was identified for 5 of 25 residents reviewed, Resident #80, #304, #306, #754, and #757. The deficient practice was evidenced by the following: 1. On 3/15/22 at 12:15 PM, the surveyor reviewed the electronic medical records (EMRs) and could not find documented evidence that an Initial Social Service Assessments ([NAME]) was completed for Residents #80, #304, and #306. On 3/16/22 at 8:59 AM, the Center Nurse Executive (CNE) provided the surveyor with the ISSAs for Resident #80, #304, and #306. A review of Resident #80's admission Record reflected an admission date of 2/8/22. A review of the resident's [NAME] revealed that the [NAME] was documented, completed and signed on 3/15/22 in the EMR. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to provide documentation that the resident declined an Advance directive (AD). This deficient practice was identified for 1 of 7 residents reviewed for Advanced Directives (Resident #50), and was evidenced by the following: On 03/14/22 at 10:27 AM, 3/15/22 at 10:09 AM, and 03/16/22 at 9:47 AM, the surveyor attempted to interview Resident #50, and the resident was not available. The surveyor reviewed the medical record of Resident #50. A review of the resident's admission Record (face sheet) reflected that Resident #50 was admitted to the facility in January 2022 with diagnoses that included, End-stage renal disease (kidney failure), Congestive heart failure, Type two diabetes, and Complete and traumatic amputation. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to accurately code a resident's Minimum Data Set (MDS) for falls in accordance with the Resident Assessment Instrument (RAI) Manual (a guide for completing resident assessments). This deficient practice was identified for 1 of 1 residents reviewed for falls, (Resident #2) as was evidenced by the following: On 03/14/22 at 10:24 AM, the surveyor observed Resident #2 lying in bed. The surveyor further observed a discoloration on the resident's left eye, cheek bone and temple area that was purple, reddish-blue, and yellow in color. The surveyor attempted to interview the resident on how he/she obtained the bruise and the resident stated, they were taking [name redacted] to see the monkeys and the monkey got [name redacted]. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to a.) obtain a physician order for Code Status upon readmission for 1 of 7 residents reviewed (Resident#50 ), b.) administer an over the counter medication as indicated in the directions on the medication bottle for 1 of 4 residents observed during medication pass (Resident # 308), and c.) ensure that treatments were administered according to Physician's Orders and professional standards of clinical practice for 1 of 1 resident reviewed for skin conditions (Resident #757). This deficient practice was 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: [...]

Inspectors wroteBased on observation, interview, and review of facility policies, it was determined the facility failed to maintain proper kitchen sanitation practices to prevent the development of food born illnesses. This deficient practice was observed during two of three kitchen tours and was evidenced by the following: On 3/14/22 at 9:38 AM, the surveyor conducted an initial tour of the kitchen with the Lead [NAME] in the presence of a second surveyor and observed a white wall mounted oscillating fan in the upper corner above the hand washing station. The fan was observed blowing visible debris consisting of black long fuzzy strands on the clean dishes in the conveyor belt area of the dishwasher. The surveyor further observed a small beige, plastic, uncovered garbage receptacle without a lid or liner containing trash under the hand-washing sink. [...]

Inspectors wroteBased on observation, interview and review of facility documents it was determined that the facility failed to ensure a.) a Temporary Nurse's Aide (TNA) appropriately donned (applied) and doffed (removed) an N95 mask before entering and exiting a resident's room who was on Transmission Based Precautions (TBP) for Covid-19, and b.) the TNA appropriately disinfected her eye protection after exiting the same room with the available disinfectant wipes. This deficient practice was evidenced by the following: According to the U.S. CDC How to Use Your N95 Respirator, updated 3/16/22, included 4. Keep Your N95 Snug: Your N95 must form a seal to your face to work properly. Your breath must pass through the N95 and not around its edges. Jewelry, glasses, and facial hair can cause gaps between your face and the edge of the mask. The N95 works better if you are clean shaven. [...]