Cranford Park Care

Inspectors wroteCOMPLAINT #2728237 Based on interviews, review of medical records and other pertinent facility documentation on 5/26/26, it was determined that the facility failed to: a) appropriately reconcile a resident's medication at time of admission and b) administer an antibiotic treatment in a timely manner in accordance with professional standard of practice. This deficient practice was identified for 1 of 2 residents (Resident #6) reviewed for medication reconciliation and was evidenced by the following:Resident #6 was not at the facility at the time of the survey. A closed record review was conducted. A review of Resident #6's admission Record revealed that the resident was admitted with diagnoses that included but were not limited to: [...]

Inspectors wroteComplaint #2966196, 2955245Based on interviews, record review, and review of other pertinent facility documents it was determined that the facility failed to a) ensure that care and services for a resident's colostomy was provided and b) resident's behaviors related to care and services of the colostomy were monitored and documented in the medical record. This deficient practice was identified for 1 of 2 closed medical records reviewed (Resident #2) for ostomy care. Resident #2 was no longer at the facility. A closed medical record review was conducted. According to the admission record, Resident #2 was admitted to the facility with diagnoses including but not limited to: encounter for attention to ileostomy (a surgical procedure that reroutes waste out of your body by connecting the lowest part of the small intestine (the ileum) to an opening in your abdominal wall, called a stoma); [...]

Inspectors wroteBased on observation, interview and review of other facility documentation it was determined that the facility failed to maintain the resident environment, and living areas in a safe, sanitary, and homelike manner. This deficient practice was evidenced by the following: On 10/31/25 at 10:30 AM, the surveyor observed the following conditions while touring the building from 9:30 AM to 11:30 AM:The carpet on the stairway leading to the B unit was heavily soiled and ripped. Heavy dust and debris accumulation on the stairwell leading to the B Unit. The corridor leading to the nourishment room of the B-Unit, had a broken exposed pipe with visible debris around.room [ROOM NUMBER] had a leaking air conditioner cover which was yellow stained. A white yellow stained towel was noted on the windowsill next to the air conditioner. The windows in the room were covered with dust. [...]

Inspectors wroteBased on observations, interviews, and policy review, the facility failed to ensure the kitchen ceiling was clean above ready-to-eat foods and staff performed adequate hand hygiene when serving meals. The failures had the potential to increase the prevalence and spread of foodborne illness and infection for all 67 of 69 facility residents who received food prepared in the kitchen.

Inspectors wroteBased on observation and interview, the facility failed to ensure garbage was covered in area near the entrance to building A next to the stairs down to the kitchen entrance. This failure had potential to cause avoidable pest infestation that could affect all 69 facility residents.

Inspectors wroteBased on observations, interviews, and policy review, the facility failed to ensure menus were followed for the five residents (Resident (R) 41, R47, R48, R2, and R79) who received a pureed diet out of a facility census of 69. The failure had the potential to contribute to weight loss, malnutrition, or lack of satisfaction with meals for these residents.

Inspectors wroteBased on observation, interview, medical record review, and policy review, the facility failed to follow standard infection control practices for three of the 18 sample residents (Resident (R) 25, R71, and R3). The facility failed to ensure proper personal protective equipment was available for use, proper PPE disposal was available, that staff donned and doffed PPE appropriately, and that hand hygiene was conducted during wound care. These failures increased the risk of the spread of infections and COVID-19 among staff and residents.

Inspectors wroteBased on interview, medical record review and policy review, the facility failed to allow one of one resident (Resident (R) 33) reviewed for care planning in a sample of 18 residents the right to participate in the development and implementation of her person-centered plan of care. This failure increased the risk that the resident would not have any direct input into her plan of care.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to provide the residents and/or their representatives with written information of the right to accept or refuse medical or surgical treatment and/or formulate an advance directive for two of 18 sample residents (Resident (R) 11 and R17) reviewed for Advanced Directives. This failure created the potential for the residents' wishes not to be followed if the residents were unable to speak for themselves.

Inspectors wroteBased on record review, interviews, and policy review, the facility failed to ensure written notice to the resident or representative of the transfer to the hospital included a statement of the appeal rights, information on how to file an appeal, and appeals contact information for two of two residents (Resident (R) 73 and R2) reviewed for hospitalization in a sample of 18 residents. This failure created the potential for a lack of understanding of appeal rights should the resident not be permitted to return or disagree with the reason for transfer, potentially causing confusion or distress upon transfer.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure the Minimum Data Set (MDS) accurately reflected the presence of a stage III pressure ulcer for one of three residents (Resident (R) 71) reviewed for pressure ulcers out of a sample of 18. This failure created potential for an incomplete or ineffective plan of care related to pressure ulcer treatment and healing measures.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure one of three residents (Resident (R) 71) reviewed for pressure ulcers out of a sample of 18 received physician-ordered pressure ulcer prevention measures. This failure created potential for development of avoidable pressure ulcers and associated risks for pain, infection, and slow healing.

Inspectors wroteCOMPLAINT #NJ00179350, NJ00182926 Based on interviews, medical record review, and review of other pertinent facility documents on 6/3/25, 6/5/25, and 6/19/25 it was determined that the facility failed to consistently document in the Documentation Survey Report on care provided to dependent residents according to facility policy and protocol for 3 of 3 residents (Resident #1, Resident #5, and Resident #6) reviewed for documentation. This deficient practice was evidenced by the following: 1. According to the admission Record (AR), Resident #1 was admitted with diagnoses that included but were not limited to: [...]

Inspectors wroteComplaint #NJ 00182926 Based on interviews, medical records reviews, and review of other pertinent facility documentation, on 06/03/25, 06/05/25, and 06/19/25, it was determined that the facility failed to revise a care plan after an annual assessment for a cognitively impaired resident that needed assistance with meals. The facility also failed to follow its Care Plan policy. This deficient practice was identified for 1 of 3 residents (Resident #6) reviewed for care plans and was evidenced by the following: Resident #6 was not at the facility at the time of the survey. A closed record review was conducted. According to the admission Record (AR), Resident #6 was admitted to the facility with diagnoses which included but were not limited Alzheimer's Disease, Dementia, Muscle Weakness, Diabetes Mellitus and Encounter for Palliative Care. [...]

Inspectors wroteBased on interview and record review it was determined that the facility failed to submit their Payroll Based Journal (PBJ) Report to the Centers for Medicare and Medicaid Services (CMS) within a timely manner. This deficient practice was identified for the PBJ Report submission for Fiscal Year (FY) Quarter 1 2024 (October 1-December 31) and was evidenced by the following: A review of the PBJ Staffing Data Report CASPER Report 1705D reflected a triggered area indicating the facility failed to submit data for the first Fiscal Year Quarter to CMS. The dates of the first quarter included October 1, 2023, through December 31, 2023. On 3/19/24 at 10:00 AM, the Licensed Home Administrator (LNHA) informed the survey team that the facility used a third party to submit the PBJ Staffing Data Report to CMS. [...]

Inspectors wroteBased on the interview and record review, it was determined that the facility failed to complete and submit electronically the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care of all residents, within 14 days of completing the resident's assessment and in accordance with the Center's for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Manual. This deficient practice was identified for 7 of 19 residents (Resident #41, 9, 53, 3, 50, 66, and #10) and reviewed for resident assessment. According to the Long-Term Care RAI 3.0 User's Manual Version 1.18.11, updated October 2023, the MDS is a comprehensive tool and a federally mandated process for clinical assessment of all residents. It must be completed and transmitted to the Quality Measure System. [...]

Inspectors wroteBased on the interview and record review, it was determined that the facility failed to code the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care of all residents, accurately for 5 of 19 residents reviewed (Resident # 69, # 9, # 57, #63, and # 24). The deficient practice was evidenced by the following: 1. The surveyor reviewed Resident # 69's records. The resident was discharged from the facility and according to the Discharge Return Anticipated MDS, an assessment tool used to facilitate the management of care, dated 2/23/24, the resident was assessed as being discharged to the hospital. A review of Resident # 69's progress notes dated 2/23/24 revealed the resident had actually been discharged home, against medical advice. [...]

Inspectors wroteBased on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to implement an intervention timely that was recommended by the wound physician. This deficient practice was identified for one of one resident (Resident #28) reviewed. This deficient practice was evidenced by the following: On 3/18/24 at 11:02 AM, the surveyor observed the Resident #28 lying in bed on an air mattress. The resident responded to questions in a faint voice. The resident gave permission to speak with the spouse who was in the room. The spouse stated, [The resident] came here because of a stroke about six months ago. On 3/18/24 at 11:26 AM, the surveyor interviewed the daughter who stated, [the resident] was in the hospital in New York for gastrointestinal bleed and has renal cancer that metastasized to the brain. [...]

Inspectors wroteBased on observation, interview, and review of other pertinent facility documents, it was determined that the facility failed to ensure a.) implementation of interventions designed by the occupational therapist to stimulate functional performance, and prevent further decline, and b.) the interdisciplinary team provided timely revision to the care plan (CP). This deficient practice was identified for one (1) of one (1) resident reviewed for limited range of motion, Resident #29 and was evidenced by the following: 1. On 3/25/24 at 10:33 AM, the surveyor observed the resident with one foot out of the blanket, the chest, and both hands were covered with a blanket. On 3/26/24 at 9:24 AM, the surveyor and the Certified Nursing Assistant (CNA) assigned to the resident, entered the resident's room. The resting hand splint (RHS; [...]

Inspectors wroteBased on observation, interview, record review, and review of other pertinent facility provided documentation, the facility failed to a) follow through with the Dietitian's recommendation for one (1) of two (2) residents (Resident #24), b) ensure the Interdisciplinary team (IDT) was aware of the resident's significant weight loss according to the standard of clinical practice for one (1) of two (2) residents (Resident #24), and c) ensure that the re-weigh was done according to the standard of clinical practice and facility policy for two (2) of two (2) residents, Resident #24 and #57, reviewed for nutrition. 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, record review, and review of other pertinent facility documentation, it was determined that the facility failed to a.) maintain the necessary care and maintenance of a respiratory equipment and b.) provide a physician's order for respiratory care in accordance with professional standards of practice for one of one resident, (Resident #58) reviewed for respiratory care. This deficient practice was evidenced by the following: On 3/18/24 at 10:35 AM, the surveyor observed the Resident #58 lying in a low bed to the ground. A nebulizer mask was on the bedside table in a bag and the label on the tubing was dated 3/11/24. The resident was pleasant, alert, and oriented to person, place and time. The resident stated, I am here because I have pneumonia (an infection of the lungs) and I need to get my breathing better again. [...]

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to provide pharmaceutical services in accordance with professional standards by ensuring that an expired controlled drug (Lorazepam gel) was removed from active inventory after 1/22/24 and had accurate corresponding documentation for the removal and administration for Resident #39 in one (1) of three (3) medication carts observed during the medication storage inspection. 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 interview, and record review, it was determined the facility failed to follow professional standards and practices to accurately document in the medical record an ordered medication a resident was being administered. The concern was cited for 2 (Residents #57 and #377) of 19 residents reviewed and is evidenced by the following. 483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are (ii) accurately documented. 1. On 3/19/24 at 12:51 PM, the surveyor reviewed the medication orders for resident #377 in the electronic medical record (EMR). The medication orders reflected that resident #377 had a physician's order for and was being administered Lantus insulin (Lantus) (a long-acting injectable medication used to treat diabetes). [...]

Inspectors wroteBased on observation, interview, record review, and review of facility provided documents, it was determined that the facility failed to ensure that a Significant Change in Status Assessment (SCSA) was completed for Resident #24. This deficient practice was identified for one (1) of 19 residents reviewed, and was evidenced by the following: According to the MDS (minimum data set) 3.0 RAI (Resident Assessment Instrument) Manual included that the SCSA is a comprehensive assessment for a resident must be completed when the IDT (interdisciplinary team) has determined that a resident meets the significant change guidelines for either major improvement or decline. A significant change is a major decline or improvement in a resident's status that: 1. [...]

Inspectors wroteBased on observation, interview and review of the medical record and review of other facility documentation, it was determined that the facility failed to maintain professional standards of clinical practice by failing to assess the fall risk for a resident that was at risk for falls and had a fall according to the facility policy for 1 of 2 residents reviewed for falls (Resident #63). This deficient practice was evidenced by the following: Reference: New Jersey Statues, Annotated Title 45, Chapter. Nursing Board The Nurse Practice Act for the State of New Jersey states; [...]

Inspectors wroteBased on interview, medical record review, and review of other pertinent facility documents, it was determined that the facility failed to offer a resident a pneumococcal vaccine for 1 of 6 residents reviewed for immunizations (Resident #63). The deficient practice was evidenced by the following: The surveyor reviewed Resident #63's medical record. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to maintain the resident's living environment in a clean, comfortable, homelike manner. This deficient practice was identified on 3 of 3 nursing units, (A-unit, B-unit, and C-unit) reviewed for environmental concerns and for 1 of 1 resident, (Resident #63) reviewed for tube feedings. This deficient practice was evidenced by the following: 1. On 09/06/23 at 12:11 PM, the surveyor toured the C-unit, entered room C5 and observed that the white molding on the bottom of the wall which was in contact with the floor was stained with yellow and black discolorations. In addition, the top of the molding behind the bed's headboard that was positoned on the same wall as the door entryway was chipped off, exposing discolored brownish-black wood. [...]

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), an assessment tool used to facilitate the management of care, for 1 of 20 resident's, (Resident #8) reviewed for accurately coding the MDS. The deficient practice was evidenced by the following: On 09/06/23 at 12:06 PM, the surveyor observed Resident #8 seated in his/her reclining chair in the main dining/activity room on the C unit. The resident was observed bopping their head to music that was playing in the background. The surveyor reviewed the medical record for Resident #8. [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documentation, it was determined that the facility failed to clarify a Physician's Order (PO) for the dosage of a medication on the electronic Medication Administration Record (eMAR) for several months. This deficient practice was identified during the medication pass observation for 1 of 6 residents, (Resident #16) reviewed and 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, interviews and review of facility documentation it was determined that the facility failed to: a.) properly handle and store potentially hazardous foods in a manner that is intended to prevent the spread of food borne illnesses and b.) maintain equipment and kitchen areas in a manner to prevent microbial growth and cross contamination. This deficient practice was observed and evidenced by the following: On 09/05/23 at 10:25 AM, the surveyor toured the kitchen in the presence of the Food Services Director (FSD) and observed the following: 1. On a metal rack in the refrigerator, there was an opened box labeled bacon with the inner plastic bag open and the bacon visible and exposed to air. The FSD acknowledged that the bacon should not have been exposed to air and stated that it was important to make sure the bacon was covered properly to avoid sickness. 2. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to: a.) appropriately label, date and store biologicals and b.) discard medications after the manufacturer specified use by date. This deficient practice was identified during 2 of 2 medication storage room (B-unit medication storage room and C-unit medication storage room) inspections and was evidenced by the following: 1. On [DATE] at 11:54 AM, the surveyor inspected the medication storage room on the B Unit. The surveyor observed one unlabeled clear orange pill bottle which contained an unidentified clear liquid. The surveyor interviewed the Licensed Practical Nurse (LPN) at the time of inspection who stated that she could not identify what type of liquid was being stored in the clear orange pill bottle on the counter of the medication storage room. [...]

Inspectors wroteBased on observation, interviews, and review of facility documentation, it was determined that the facility failed to follow appropriate infection control practices and perform hand hygiene as indicated during dining observation for 1 of 3 units, (B unit). The deficient practice was evidenced as follows: On 09/07/23, the surveyor observed the following during lunch meal pass on the B-unit: At 12:36 PM, in the pantry room, a Recreation Aide (RA) removed the ice scoop from the wall holder and scooped ice from a cooler, poured the ice into a cup, replaced the ice scoop to the holder, placed the cup on a meal tray and placed the tray on Resident #16's bedside table in his/her room. The RA returned to the pantry and retrieved a meal tray and placed it on Resident #46's side table in his/her room. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to complete and transmit the discharge Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, for a resident that was discharged from the facility. This deficient practice was identified for 1 of 1 unsampled resident, (Resident #31) reviewed in the Resident Assessment Task for MDS record over 120 days old. The deficient practice was evidenced by the following: On 09/13/23 at 1:06 PM, the surveyor reviewed Resident #31's MDS history in the presence of the Minimum Data Set Coordinator (MDSC). The surveyor and MDSC reviewed the resident's medical record and identified that the MDS history did not reveal that the resident was discharged from the facility. The surveyor independently reviewed the medical record for Resident #31. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to post the Nursing Home Resident Care Staffing Report daily. This deficient practice was evidenced by the following: On 09/05/23 at 9:00 AM, the surveyor entered the facility (on the Tuesday after Labor Day weekend) and observed that the Nursing Home Resident Care Staffing Report posted in the front lobby was dated 09/01/23 (Friday). On 09/13/23 at 12:21 PM, the surveyor interviewed the Licensed Practical Nurse/Infection Preventionist (LPN/IP) who stated that the Staffing Coordinator (SC) was responsible for posting the daily staffing Monday through Friday. The LPN/IP told the surveyor that on weekends the Supervisor or Receptionist would post the daily staffing. [...]