Below average — CMS composite of the measures below.
The next survey window likely opens around November 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 Cranbury Center during CMS and state inspections, most recent first.
Improper Physical Restraint Used During Respiratory Treatment: An RN secured a resident’s left hand to the side rail with a pillowcase while attempting to administer a nebulizer treatment after the resident became combative and removed the mask. The resident had dementia, severe cognitive impairment, respiratory failure, and functional quadriplegia, and the restraint was later observed by the hospice nurse and confirmed in the facility’s event investigation.
A resident who wished to be DNR had conflicting code status information in the EMR, with both Full Code and DNR orders active at the same time. Staff reported they relied on the EMR dashboard and physician orders to determine code status during an emergency, and some stated they would start CPR if two code statuses were listed while another staff member contacted the family. The resident’s paper chart also contained a POLST indicating DNR, but the earlier Full Code order was not discontinued when the DNR order was entered.
Kitchen sanitation and food storage deficiencies were identified during a kitchen tour. A sanitizer bucket used for wiping cloths tested at 0 PPM, the ice machine had food and water stains, dry storage ingredient bins were unlabeled and undated, dish storage containers and lids were dirty, a broken coffee urn was still in use with packing tape at the bottom, and a steam table pan cover had dried gravy buildup. The DM stated the cleaning schedule was not in writing and confirmed that sanitizer buckets, labeled storage, clean dish containers, and removal of broken equipment were expected.
MDSs did not accurately reflect PASRR Level II status for four residents. One resident’s annual MDS omitted Mental Illness/Level II despite a prior PASARR I referral, two residents with bipolar disorder and schizophrenia had Level 2 PASRRs with mental health treatment needs but their MDSs did not note Level 2 PASRR, and another resident with bipolar disorder had an MDS stating the state did not consider the resident to have SMI/ID even though the care plan identified PASRR II status.
Failure to Protect a Resident from Abuse: A resident with severe dementia and agitation struck another resident after being told to go away. The other resident had bipolar disorder, adjustment disorder, and moderately impaired cognition. A staff member witnessed the incident, and the resident who was struck reported being hit on the chin. The DON and Administrator described the event as isolated.
Failure to Track Target Behaviors and Monitor Antipsychotic Side Effects: The facility failed to identify targeted behaviors, track behaviors, and monitor antipsychotic side effects for two residents receiving psychotropic medications. One resident with schizophrenia received Zyprexa, and another resident with paranoid schizophrenia received Risperidone, but the MARs, notes, and physician orders did not document specific behaviors or side effects to monitor. Staff interviews confirmed they were not instructed on specific behaviors or medication side effects to observe.
Failure to report a verbal abuse allegation within the required timeframe occurred when one resident reportedly threatened another over a cigarette and the allegation was not reported for two residents. An RN said she heard about the threat later, did not witness it, did not interview other staff, and did not report it, while the DON said she learned of it the next morning and did not report it because the resident later denied it and said he felt safe. The facility policy required abuse allegations, including verbal abuse, to be reported within 2 hours.
The facility failed to thoroughly investigate allegations of verbal abuse involving two residents and a physical abuse allegation involving another resident. One resident with schizophrenia reportedly threatened another resident over a cigarette, but staff who supervised smoking and other residents were not interviewed, and the DON relied on the resident saying nothing occurred. In a separate incident, a resident with severe dementia with agitation was reported to have hit another resident on the chin, but only one staff member was interviewed and no residents were interviewed, despite policy requiring a timely, thorough abuse investigation.
Failure to invite a cognitively intact resident to care plan conferences and failure to hold a quarterly care planning meeting for another resident. Care conference notices were sent to family members rather than the resident, with no documentation that the resident was notified, and the resident stated she was unaware of any care conference and had never attended one. For the other resident, the record showed no evidence of quarterly care planning meetings, and the MDSC confirmed there was no process in place for determining invitations or scheduling care plan meetings.
The facility failed to provide a homelike dining environment by serving meals on trays directly from the cart to tables without removing the food from the trays for 16 residents on Unit C. Staff, including CNAs and an LPN, confirmed this practice, which was acknowledged by the DON and Administrator as resembling a cafeteria setting. This practice contradicted the facility's policy on maintaining a homelike environment.
The facility failed to ensure cooking vessels were completely air-dried before storage, as observed during a survey. Buffet pans and other vessels were found stacked while still wet, which was confirmed by the CM and FSD. The facility's policy requires all dishware to be air-dried and properly stored, a requirement that was not met, as verified by the Administrator.
A resident with severe cognitive impairment was fed by an LPN who stood while assisting with the meal, contrary to facility policy requiring staff to sit to maintain resident dignity. The LPN cited the absence of a chair as the reason for standing, aiming to serve the meal warm. The DON and interim Administrator confirmed the expectation for staff to sit during meal assistance.
A facility failed to follow a physician's order for a resident's right-hand splint, which was supposed to be worn daily for 6-8 hours. The resident, with a history of hemiplegia and hemiparesis, was observed not wearing the splint, which was found on the dresser. The resident confirmed the splint was not applied by staff, and an LPN acknowledged the importance of wearing it to maintain range of motion. The DON and Administrator expected physician orders to be followed, as per facility policy.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a suprapubic catheter, PICC line, and multiple wounds, despite staff training on EBP. Observations showed no EBP sign or PPE cart outside the resident's room, and staff did not wear gowns during care. The interim Infection Preventionist and Nurse Manager acknowledged the oversight, which was contrary to the facility's EBP policy.
Improper Physical Restraint Used During Respiratory Treatment
Penalty
Summary
The facility failed to keep a resident free from the use of a physical restraint when RN#1 used a pillowcase to wrap around the resident’s left hand and tied it to the side rail during a nebulizer treatment. The resident was observed with the restraint by the hospice nurse, and the device was later removed by the Manager on Duty. The survey identified this as a deficiency involving 1 of 6 residents reviewed for restraint. The resident involved had diagnoses including unspecified dementia, major depression, respiratory failure, and functional quadriplegia. The resident’s MDS showed a BIMS score of 3 out of 15, indicating severely impaired cognition. The care plan identified the resident as resistive and combative with care related to cognitive loss/dementia, and the physician’s order summary included ipratropium-albuterol every 6 hours as needed for shortness of breath or wheezing. RN#1 stated the resident became combative and pulled off the nebulizer mask during the respiratory treatment, and she then secured the resident’s left hand to the side rail with a pillowcase to ensure the treatment was received. RN#1 later stated she should have called the medical doctor for refusal and documented the refusal. The facility reportable event and staff interview both confirmed that the resident’s left upper extremity had been secured to the enabler with a pillowcase during the treatment.
Conflicting Code Status Orders for a Resident
Penalty
Summary
The facility failed to ensure that Resident #61’s code status was accurately documented in the EMR to reflect the resident’s wishes in the event of a medical emergency. The resident wanted to be DNR, but the EMR listed the code status as DNR/Full Code. Staff interviews showed that during an emergency response, they would initiate CPR while another staff member called the resident’s family to verify wishes if the code status was unclear or conflicting. Resident #61’s EMR contained two active physician orders that conflicted with each other: one order for Full Code and a later order for DNR. The earlier Full Code order was not discontinued when the DNR order was entered, resulting in contradictory code status information in the EMR. The resident’s paper chart also contained a POLST indicating DNR. Interviews with nursing staff and the IP/LPN showed that staff used the EMR dashboard and physician orders to identify code status, and that the discrepancy was not corrected when the new order was entered. The DON stated that when a resident’s code status changed, the old order should be discontinued when the new order was placed. The report states this created an Immediate Jeopardy situation because the resident’s wishes might not be followed during an emergency response.
Kitchen sanitation and food storage deficiencies
Penalty
Summary
The facility failed to keep kitchen and food service areas sanitary during an initial kitchen tour with the Dietary Manager. Observations showed a sanitary bucket used for wiping cloths tested at 0 PPM sanitizer, the lower front of the ice machine was covered in splattered food and water stains, and four ingredient bins in the dry storage room containing flour, breadcrumbs, sugar, and rice were not labeled or dated. Two plastic containers used to hold cups and small dessert bowls had lids with a dirty film and sticky crumbs, and one bowl inside had dried pudding in it. Additional observations showed a large coffee urn had approximately six inches of packing tape at the bottom because it was broken but was still being used until a new one arrived. A steam table pan cover had hard gravy drippings measuring approximately 4 inches long and 1/2 inch wide. The Dietary Manager stated the cleaning schedule was not in writing, that the ingredient bins should be labeled and dated, that sanitizer buckets should be changed every two hours and maintain the required PPM, that only clean dishes should be stored in clean containers, and that broken equipment should be thrown away and replaced. The Administrator stated kitchen sanitation policies should be followed and broken items should be discarded and replaced.
MDSs Did Not Accurately Reflect PASRR Level II Status
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) accurately reflected PASRR Level II status for four residents: R70, R11, R77, and R20. Review of R70’s annual MDS with an ARD of 06/29/25 showed no indication of Mental Illness or Level II services, even though the resident’s PASARR I dated 04/03/18 showed a referral for Level II. During interview, the MDSC stated the MDS assessments in section A of the Level II PASARR conditions were done incorrectly per the RAI manual and would need to be modified, and that all residents should have had PASRR Level II indicated on section A of their comprehensive assessments. R11 was admitted with bipolar disorder and major depressive disorder, and a Level 2 PASRR dated 03/12/25 indicated mental health treatment needs that could be met in a nursing facility, including psychiatric consultation, follow-up visits, medication monitoring, supportive counseling, lab testing, behavioral modification planning, education, and a crisis intervention/safety plan; however, the annual MDS with ARD 03/31/25 did not note Level 2 PASRR. R77 was re-admitted with schizophrenia, and a Level 2 PASRR dated 05/26/21 contained similar mental health treatment recommendations, but the significant change MDS with ARD 02/23/25 did not note Level 2 PASRR. R20 was admitted with bipolar disorder; the annual MDS with ARD 01/24/25 stated the resident was not currently considered by the state Level II PASRR process to have a serious mental illness and/or intellectual disability or related condition, while the care plan later identified that R20 met PASRR II Level of Determination secondary to serious mental illness. The MDSC stated R20’s MDS was inaccurate and would be corrected, and the Administrator stated that all MDSs should be accurate upon submission.
Failure to Protect a Resident from Abuse
Penalty
Summary
The facility failed to ensure that one resident was free from abuse when a staff-witnessed altercation occurred between two residents. One resident, who had severe dementia with agitation and did not respond to interview questions, approached another resident, who had bipolar disorder and adjustment disorder with mixed anxiety and depressed mood and a BIMS score of 12 out of 15, indicating moderately impaired cognitive function. According to the resident interview and the facility reported incident summary, the resident told the other resident to go away, and the other resident hit him on the chin. The incident summary stated that both residents were immediately separated and skin assessments were completed with no apparent injuries noted. During interview, the resident who was struck stated the other resident hit him after being told to go away and denied prior incidents. The team documented that the resident who struck the other resident became agitated due to declining cognitive status. The DON and Administrator both stated the event was isolated and no further occurrences had been reported.
Failure to Track Target Behaviors and Monitor Antipsychotic Side Effects
Penalty
Summary
The facility failed to identify targeted behaviors, conduct behavior tracking, and monitor side effects of antipsychotic medications for two residents receiving psychotropic drugs. One resident had diagnoses including schizophrenia, a BIMS score of 13 out of 15, and was ordered Zyprexa 10 mg in the evening for schizophrenia. Review of the MARs for October, November, and December 2025 found no documented evidence showing which specific behaviors or side effects were associated with the antipsychotic medication, and the nurse's notes for the same period did not document behaviors related to schizophrenia. During interviews, an LPN and an RN stated they had not been instructed to look for specific behaviors or side effects for each medication, and the DON stated she was unaware staff were not monitoring target behaviors or side effects. A second resident had diagnoses including paranoid schizophrenia and a BIMS score of 15 out of 15. The resident received Risperidone 1 mg twice daily, and the care plan documented a history of paranoia, screaming and cursing at others, hallucinations, punching others, and racial slurs toward staff. However, the physician orders did not include behavior tracking or monitoring for antipsychotic side effects, and the MAR/TAR entries only stated to chart behaviors every shift without identifying the specific behaviors to track. During interviews, the DON stated there were no orders for the specific behaviors, an LPN stated the resident did not have targeted behaviors documented in the physician orders but should have, and the Administrator stated she expected staff to ensure targeted behaviors and medication risks were identified and monitored.
Failure to Report Verbal Abuse Allegation Within Required Timeframe
Penalty
Summary
The facility failed to report an allegation of verbal abuse within two hours for two residents, one with schizophrenia and another with anxiety disorder and bipolar disorder. Review of the medical record showed that during the 3-11 shift, one resident reportedly threatened the other by stating he was going to blow his head off if he did not give him a cigarette, while cursing and causing a disturbance in the hallway. The episode was documented as having been managed at the time. During interview, an RN stated that later that day the resident who was threatened came upstairs and told her that the other resident had threatened to shoot him because he would not give him a cigarette. The RN stated she did not witness the interaction, did not speak with staff who supervised smoking or with other residents, and did not report the allegation, although she said she should have. The DON stated she was not made aware of the incident until the next morning and said she did not feel the need to report it because she spoke with the resident who denied anything occurred and said he felt safe. The facility policy required allegations involving abuse, including verbal abuse, to be reported not later than two hours after the allegation was made.
Incomplete Investigation of Abuse Allegations
Penalty
Summary
The facility failed to thoroughly investigate allegations of verbal abuse involving two residents. One resident with schizophrenia was reported to have threatened another resident by saying he was going to blow his head off if he did not give him a cigarette, while cursing and causing a disturbance in the hallway. The DON was made aware of the incident, but the investigation did not include interviews with staff who supervised smoking or with other staff, and no residents were interviewed, including the resident who reported the threat and the resident accused of making it. During interview, an RN stated she heard the report from the resident but did not speak with the smoking supervision staff or other residents and did not report the incident, although she said she should have. The DON stated she spoke with the resident who reported the threat, who said nothing occurred and that he was not fearful, and based on that did not interview other residents or staff. The facility also failed to thoroughly investigate an allegation of physical abuse involving another resident with severe dementia with agitation. A summary documented that a staff member witnessed one resident approach another, was told to go away, and then hit the other resident on the chin. The FRI showed only one staff member was interviewed and no residents were interviewed regarding the allegation. The DON stated that only one staff member had direct knowledge of the incident and that no resident interviews were obtained, stating there were no residents involved. The facility policy required an investigation within 24 hours that focused on whether abuse occurred, clinical examination for injuries if indicated, causative factors, interventions to prevent further injury, and documentation of witnessed interviews.
Failure to Invite Resident to Care Plan Conference and Hold Required Care Planning Meeting
Penalty
Summary
The facility failed to ensure that a cognitively intact resident with chronic kidney disease was invited to care plan conferences. The resident’s EMR showed a BIMS score of 15 out of 15, and care conference notification letters were generated for meetings, but the letters were addressed to the resident’s family members with no documentation that the resident received notice. A progress note documented that a care plan meeting was held, but the resident or family did not attend. During interview, the resident stated she was not aware of any care conference and had never attended one, and said she would like to attend. Staff interviews confirmed that residents should always be invited, while the MRS stated she believed the family would notify the resident if family members were contacted. The facility also failed to hold a care plan conference for another resident with diagnoses including anxiety, chronic pain syndrome, CVA, depression, epilepsy, muscle spasms, and polyneuropathy. Review of that resident’s progress notes showed no evidence of quarterly care planning meetings being held, and the MDS Coordinator stated that prior to January 2025 there was no process in place to determine who was invited to care plan meetings or when they were scheduled. The MDS Coordinator confirmed that the resident had one in-progress care conference entry, but otherwise no record of care conferences was found in the medical record. The facility policy titled Person Centered Care Plan stated that the center has the responsibility to assist patients to participate by extending invitations in advance and facilitating patient or representative attendance.
Failure to Ensure Homelike Dining Environment
Penalty
Summary
The facility failed to ensure a homelike dining environment for residents on Unit C, as observed during a lunch meal service. Staff members delivered meal trays directly from the cart to the tables in front of 16 residents without removing the food from the trays. This practice was consistent across multiple observations and interviews with staff members, including CNAs and an LPN, who confirmed that the food was always served on trays and not removed once placed on the table. This method of serving meals was acknowledged by the Director of Nursing and the Administrator as resembling a cafeteria setting rather than a homelike environment. The facility's policy, titled 'Resident Rights Under Federal Law,' emphasizes the right of residents to a safe, clean, comfortable, and homelike environment. However, the practice of serving meals on trays in the dining room contradicts this policy. The deficiency was identified through observations and staff interviews, which revealed a routine practice that did not align with the facility's stated commitment to providing a homelike environment for its residents.
Improper Storage of Wet Cooking Vessels
Penalty
Summary
The facility failed to ensure that cooking vessels were completely air-dried before being stored, as observed during a survey. On two separate occasions, buffet pans and other cooking vessels were found stacked while still wet, which was confirmed by the Chef Manager (CM) and the Food Services Director (FSD). The CM acknowledged that all washed items should have been completely dried before stacking and storing, as per the facility's policy. This policy, titled 'Warewashing' and revised in February 2023, mandates that all dishware, service ware, and utensils be air-dried and properly stored after cleaning and sanitization. The failure to adhere to this policy was verified by the Administrator, who confirmed that nesting pans should have been completely dried before being stacked together.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to maintain the dignity of a resident during meal assistance. The incident involved a resident who was admitted with diagnoses including unspecified dementia with agitation and dysphagia. The resident required a mechanically altered diet and had a Brief Interview for Mental Status (BIMS) score indicating severe cognitive impairment. During a meal observation, a Licensed Practical Nurse (LPN) was seen standing while feeding the resident, which was acknowledged by the LPN as not maintaining the resident's dignity. The LPN stated that she could not find a chair to sit in and chose to feed the resident standing up to ensure the meal was served warm. The Director of Nursing (DON) and interim Administrator confirmed that the expectation was for nursing staff to sit while feeding residents to maintain their dignity. The facility's policy on resident rights emphasized treating each resident with respect and dignity, which includes sitting while assisting with meals. This policy was not adhered to in this instance, leading to the deficiency noted in the report.
Failure to Follow Physician's Order for Hand Splint
Penalty
Summary
The facility failed to follow a physician's order for a right-hand splint device for a resident, identified as R74, who was reviewed for range of motion among 34 sample residents. R74 was admitted with diagnoses including hypertension, hemiplegia, and hemiparesis following a cerebral infarction affecting the right dominant side, and unspecified lack of coordination. The resident's care plan required the use of a right upper extremity hand splint during the daytime for 6-8 hours, as per the physician's order dated 05/10/24. However, observations on 06/11/24 and 06/12/24 revealed that the splint was not being worn by the resident, and it was found lying on the dresser across the room. The resident confirmed that the splint was supposed to be worn daily but stated that no one had put it on him. Interviews with staff, including an LPN and the Director of Nursing, confirmed that the splint should have been worn daily and that the resident was unable to apply it independently. The LPN acknowledged the importance of wearing the splint to prevent loss of range of motion. The Director of Nursing and the facility Administrator both expressed that their expectation was for all physician orders to be followed. The facility's policy on Activities of Daily Living, dated 05/01/23, emphasized the necessity of providing care and services to maintain or improve a patient's ADL abilities, including the use of assistive devices as needed.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to infection control and prevention guidelines by not implementing Enhanced Barrier Precautions (EBP) for a resident with a suprapubic catheter, PICC line, and multiple wounds, who was also receiving antibiotic therapy for a multi-organism wound infection. The resident, identified as R103, was admitted with several medical conditions, including quadriplegia and pressure ulcers, but the care plan did not include EBP interventions. Observations revealed that the resident's catheter bag was uncovered and attached to the bed rail, and there was no EBP sign or personal protective equipment (PPE) cart outside the resident's room. Interviews with staff, including LPNs and CNAs, confirmed that EBP was not implemented for the resident, and staff were not wearing gowns during catheter and wound care. Although staff had been trained on EBP by a former Infection Preventionist, there was confusion about which residents required these precautions. The interim Infection Preventionist and the Nurse Manager acknowledged that EBP should have been initiated upon the resident's readmission, but it was overlooked. The facility's policy on EBP, which was revised several times, outlined the need for posting EBP signs and having PPE accessible for residents with chronic wounds or indwelling medical devices. Despite this, the admitting nurse did not update the care plan or implement EBP for the resident upon readmission. The interim Infection Preventionist stated that EBP signs and PPE carts were available, but the responsibility to implement these precautions was not consistently followed, leading to a potential risk of spreading multidrug-resistant organisms.
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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 Monroe Township
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Gardens At Monroe Healthcare And Rehabilitation, T | 1.6 mi | ★★★★★ | 0 | 0 |
| The Elms Rehab And Healthcare Center Of Cranbury | 2 mi | ★★★★★ | 15 | 1 |
| Village Point | 3.2 mi | ★★★★★ | 1 | 1 |
| Meadow Lakes | 4.3 mi | ★★★★★ | 0 | 0 |
| Excel Care At Manalapan | 6.5 mi | ★★★★★ | 24 | 0 |
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