Cranford Park Care
Inspection history, citations, penalties and survey trends for this long-term care facility in Cranford, New Jersey.
- Location
- 600 Lincoln Park East, Cranford, New Jersey 07016
- CMS Provider Number
- 315390
- Inspections on file
- 17
- Latest survey
- October 31, 2025
- Citations (last 12 mo.)
- 12
Citation history
Health deficiencies cited at Cranford Park Care during CMS and state inspections, most recent first.
Surveyors found that the facility failed to maintain a safe, clean, and homelike environment, with observations including soiled and damaged carpets, dust and debris accumulation, broken exposed pipes, leaking and stained air conditioner covers, missing window treatments, and unsanitary kitchen and dumbwaiter areas. Facility staff were unaware of some issues and could not provide documentation of recent environmental rounds.
The facility did not consistently document ADL care, including personal hygiene and toilet use, for three dependent residents with cognitive impairment. Multiple days and shifts lacked required entries in the electronic medical record, despite staff and policy requirements that all care be documented. Staff interviews confirmed that documentation was incomplete and that all care provided should have been recorded.
A resident with severe cognitive impairment and multiple diagnoses required maximum assistance with eating, as documented in the MDS and care conference notes. However, the care plan was not updated to reflect this need, contrary to facility policy requiring timely care plan revisions when a resident's condition changes.
The facility failed to submit their PBJ Report to CMS for FY Quarter 1 2024 on time. The LNHA relied on a third party for submission but could not provide proof of submission. The facility's policy did not specify the timeframe or responsible party for the submission.
The facility failed to submit MDS assessments within the required 14-day period for seven residents, with delays ranging from several weeks to over a month. The MDS Coordinator cited the need for additional time to complete assessments as the reason for the delays. Facility management did not respond to the survey team's concerns.
The facility failed to accurately code the MDS for five residents, leading to discrepancies in their medical records, including incorrect discharge information, vaccination status, and missing assessment interviews. These issues were confirmed by the MDS Coordinator and other staff during interviews with the surveyor.
A facility failed to implement a timely intervention recommended by the wound physician for a resident with a stage four sacral wound. Despite multiple recommendations for a wound VAC starting from February, the facility did not apply it until late March due to a lack of communication and follow-up. The delay was acknowledged by the DON and the wound doctor, who agreed that better documentation and communication were needed.
The facility failed to implement and revise the care plan for a resident with limited range of motion, resulting in the resident not receiving the prescribed splints to prevent contracture. The interdisciplinary care plan meetings did not document the use of medical devices, and the communication between nursing and rehabilitation services was inadequate.
The facility failed to follow the Dietitian's recommendations and ensure proper weight monitoring for two residents, leading to unaddressed significant weight loss. The staff did not communicate or document the necessary actions, and the IDT was not informed of the residents' conditions.
The facility failed to maintain respiratory equipment and obtain a physician's order for a resident with a history of pneumonia, COPD, and lung cancer. The nebulizer mask and tubing had not been changed as required, and there was no physician's order for tubing changes for over nine weeks. The DON acknowledged the oversight.
The facility failed to remove an expired Lorazepam gel from inventory and accurately document its administration. An LPN and the DON acknowledged discrepancies between the IPCDR and EMAR, and the CP confirmed that expired medications should be reported and removed during monthly inspections, which was not done.
The facility failed to accurately document medications and immunizations for two residents. One resident's EMR had discrepancies in insulin documentation, while another resident's immunization records were incomplete.
A resident with multiple health issues experienced significant weight loss and developed a deep tissue injury, but the facility failed to complete a required Significant Change in Status Assessment (SCSA). The MDS Coordinator acknowledged the oversight, and facility management was notified but did not respond to the concerns.
The facility failed to maintain professional standards by not timely assessing the fall risk for a resident with severe cognitive impairment and a history of falls. The required quarterly Fall Risk Evaluation was not completed on time and was created retroactively after surveyor inquiry.
A resident with severe cognitive impairment was not offered a pneumococcal vaccine upon admission, despite facility policy requiring it. The vaccine was only administered after surveyor inquiry, revealing lapses in the verification and administration process by the staff.
Failure to Maintain Safe, Clean, and Homelike Environment
Penalty
Summary
Surveyors observed multiple deficiencies in the facility's maintenance and cleanliness during a building tour. The carpet on the stairway to the B unit was heavily soiled and ripped, and there was heavy dust and debris on the stairwell. In the corridor leading to the nourishment room of the B-Unit, a broken exposed pipe with visible debris was noted. In one resident room, a leaking air conditioner cover was yellow stained, and a stained towel was placed on the windowsill next to the unit. The windows in this room were covered with dust and lacked window treatments or drapes, providing an unrestricted view from the street. Another resident room also lacked window treatments, similarly exposing the room to the street. The residents in these rooms could not be interviewed. In the kitchen area where food was transported to the dumbwaiter, the area was heavily soiled with debris, cobwebs were present in the corner, and the lift tray was soiled and covered with debris. The Food Service Director confirmed the need for cleaning in this area. The Maintenance and Housekeeping Director stated that environmental rounds were conducted monthly and that housekeeping staff were responsible for daily cleaning, but he was unaware of the leaking air conditioner and missing drapes, and had not received a work order for the air conditioner repair. He was also unable to provide the last environmental round minutes when requested. A kitchen staff member provided a cleaning schedule indicating the dumbwaiter area was to be cleaned weekly.
Failure to Document ADL Care for Dependent Residents
Penalty
Summary
The facility failed to consistently document care provided to dependent residents in accordance with its own policies and accepted professional standards. For three residents with moderate to severe cognitive impairment and significant assistance needs for activities of daily living (ADLs), there were multiple instances where documentation of personal hygiene and toilet use was missing across all shifts for extended periods. The lack of documentation was identified through review of the Documentation Survey Reports (DSRs) and confirmed by interviews with staff, who acknowledged that all care provided should be recorded in the electronic medical record without any blanks. Specifically, for one resident with dementia and diabetes, there were numerous days in May where personal hygiene documentation was absent across all three shifts. Another resident with seizures and muscle weakness also had multiple days in May with missing documentation for personal hygiene. A third resident with Alzheimer's disease and severe cognitive impairment had extensive gaps in documentation for both personal hygiene and toilet use throughout January, with missing entries on nearly every day and shift reviewed. Interviews with CNAs, an LPN, and the DON confirmed that CNAs are responsible for documenting ADL care in the electronic record, and that there should not be any blanks in the documentation. Facility policies reviewed by surveyors also required that all skilled and unskilled services, including ADL care, be documented for each resident. The failure to document care as required was observed and verified by both staff and surveyors during the investigation.
Failure to Update Care Plan for Cognitively Impaired Resident Requiring Assistance with Eating
Penalty
Summary
The facility failed to revise and update the care plan for a cognitively impaired resident who required substantial to maximum assistance with eating, following the resident's annual assessment. The resident, who had diagnoses including Alzheimer's Disease, Dementia, Muscle Weakness, Diabetes Mellitus, and was receiving palliative care, was assessed with a BIMS score of 3/15, indicating severe cognitive impairment. The Minimum Data Set (MDS) and interdisciplinary care conference notes documented that the resident required maximum assistance with activities of daily living (ADLs), including eating. However, a review of the resident's care plan did not reflect the required level of assistance for eating. Interviews with the Director of Nursing (DON) confirmed that the care plan should have been updated to match the MDS and care conference documentation, specifically to indicate the need for maximum assistance with eating. The facility's care plan policy required timely updates and revisions to care plans when there were changes in a resident's condition. Despite this policy, the care plan was not revised after the annual assessment, resulting in a failure to ensure the care plan accurately addressed the resident's needs.
Failure to Submit PBJ Report to CMS on Time
Penalty
Summary
The facility failed to submit their Payroll Based Journal (PBJ) Report to the Centers for Medicare and Medicaid Services (CMS) within a timely manner for Fiscal Year (FY) Quarter 1 2024, covering the period from October 1, 2023, to December 31, 2023. This deficiency was identified through a review of the PBJ Staffing Data Report CASPER Report 1705D, which indicated that the facility did not submit the required data to CMS. The Licensed Home Administrator (LNHA) informed the survey team that a third party was responsible for submitting the PBJ Staffing Data Report, but there was no documentation or proof of submission provided to CMS for the specified quarter. During an interview, the LNHA stated that the third party handled the communication with CMS, but he could not provide any documentation to confirm that CMS received the data for FY Quarter 1 2024. The survey team requested the facility's policy and procedure for PBJ submission/communication to CMS, which was provided by the LNHA. The policy, revised on February 8, 2024, did not specify the timeframe for submitting data to CMS or who was responsible for the submission. This lack of documentation and clarity in the policy contributed to the failure to submit the PBJ Report on time.
Failure to Timely Submit MDS Assessments
Penalty
Summary
The facility failed to complete and submit the Minimum Data Set (MDS) assessments electronically within the required 14-day period as mandated by the Centers for Medicare and Medicaid Services (CMS) Resident Assessment Instrument (RAI) Manual. This deficiency was identified for seven residents, where the MDS assessments were significantly delayed. For instance, Resident #41's Quarterly MDS (QMDS) with an Assessment Reference Date (ARD) of 1/30/24 was not submitted until 3/6/24, well past the 2/13/24 deadline. Similar delays were observed for Residents #9, #53, #3, #50, #66, and #10, with submission dates ranging from several weeks to over a month past the required deadline. The surveyor's review revealed that the facility did not have a specific policy regarding MDS submissions and relied on the RAI Manual. The MDS Coordinator (MDSC) attributed the delays to the time needed for various disciplines to complete their assessments. Despite being informed of these findings and concerns, the facility management, including the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), Infection Preventionist Nurse (IPN), and Clinical Nurse Consultant (CNC), did not provide a response to the survey team's concerns during the exit meeting.
Inaccurate MDS Coding for Multiple Residents
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for five residents, leading to discrepancies in their medical records. For Resident #69, the MDS indicated a discharge to the hospital, while progress notes revealed the resident was discharged home against medical advice. The MDS Coordinator acknowledged the error during an interview with the surveyor. Similarly, Resident #9's MDS inaccurately reflected that the pneumococcal vaccination was up to date, despite the resident's son having refused the vaccine. Additionally, there was no record of a PHQ-9 assessment interview on the Assessment Reference Date (ARD) of 2/1/24, as required. Resident #57's MDS also contained inaccuracies, with no record of a PHQ-9 assessment interview on the ARD of 12/21/23. The Registered Nurse (RN) and MDS Coordinator confirmed the absence of these assessments during interviews. For Resident #63, the MDS inaccurately indicated that the pneumococcal vaccine was up to date, although the immunization record showed it was not administered. The MDS Coordinator admitted to inputting incorrect data and noted a discrepancy between the electronic and printed versions of the MDS. Lastly, Resident #24's MDS inaccurately stated that the resident declined the pneumococcal vaccination, despite records showing it was administered on 6/02/23. The MDS Coordinator confirmed the error and stated that the facility follows the RAI Manual for MDS assessments. These inaccuracies in the MDS coding were brought to the attention of the Director of Nursing (DON), Licensed Nursing Home Administrator (LNHA), and other facility management, who did not provide additional information or responses to the surveyor's concerns.
Failure to Implement Timely Wound Care Intervention
Penalty
Summary
The facility failed to implement a timely intervention recommended by the wound physician for a resident with a stage four sacral wound. The resident, who had multiple medical conditions including renal cancer, brain metastasis, and a history of stroke, was observed lying in bed on an air mattress. Despite recommendations from the wound care team for a wound VAC (vacuum-assisted closure) starting from February 14, 2024, the facility did not apply the wound VAC until March 22, 2024. The delay in implementing the wound VAC was due to a lack of communication and follow-up between the wound care team and the facility staff. The resident's care plan and medical records indicated that the resident had a sacral pressure ulcer on admission and required maximal to total assistance with activities of daily living. The wound care team had recommended the wound VAC protocol multiple times, but there was no evidence of an order or treatment clarification from the facility. The Director of Nursing (DON) and Licensed Practical Nurses (LPNs) interviewed during the survey confirmed that they had not received any orders for the wound VAC until March 22, 2024. The wound doctor also acknowledged that the wound VAC was on back order in February 2024 and that better documentation and communication were needed. The facility's policy and procedure for wound care indicated that preventative measures should be instituted to prevent the development or further deterioration of skin integrity. However, the facility did not provide any documentation of the wound VAC being on back order or that the recommendation for the wound VAC was clarified. The delay in applying the wound VAC was discussed with the DON and the wound doctor, who agreed that the recommendation should have been communicated and documented better. The resident's family was informed about the wound VAC application, and the procedure was eventually carried out on March 22, 2024.
Failure to Implement and Revise Care Plan for Resident with Limited Range of Motion
Penalty
Summary
The facility failed to implement interventions designed by the occupational therapist to stimulate functional performance and prevent further decline for a resident with limited range of motion. The resident, who was dependent and required total care, was observed without the prescribed resting hand splint and elbow extension splint. The CNA assigned to the resident stated that the resident often refused the splint, but the electronic communication record did not reflect any task associated with the splint. Additionally, the CNA reported to the medication nurse, who documented the donning, doffing, and refusals of the splint in the electronic medical record, but the system did not show these tasks being assigned to the CNA. The resident's medical record indicated severe cognitive impairment and a history of conditions such as unspecified convulsions, cerebellar stroke syndrome, and unspecified dementia. The occupational therapy discharge summary recommended the use of a resting hand splint and an elbow extension splint, but these were not included in the physician orders or the care plan. The resident was observed without the prescribed splints, and the care plan did not reflect the necessary interventions to prevent contracture. The interdisciplinary care plan meetings did not document the use of medical devices, and the communication between nursing and rehabilitation services was inadequate. The facility's policies on restorative programs and care plans were not followed, leading to the failure to implement and revise the care plan as needed.
Failure to Follow Nutritional Recommendations and Weight Monitoring
Penalty
Summary
The facility failed to follow through with the Dietitian's recommendation for a resident, ensure the Interdisciplinary team (IDT) was aware of the resident's significant weight loss, and ensure that re-weighs were done according to the standard of clinical practice and facility policy. Specifically, Resident #24 experienced significant weight loss, and the Dietitian recommended an albumin level check, which was not followed through. The Licensed Practical Nurse (LPN) and Registered Dietitian (RD) were unaware of the significant weight loss and the recommendation was not communicated to the physician or documented properly in the medical records. Resident #24, who had diagnoses including essential hypertension, osteoarthritis, glaucoma, type 2 diabetes mellitus, and dementia, was observed in a geri chair with eyes closed. The resident's comprehensive Minimum Data Set (cMDS) indicated severe cognitive impairment and significant weight loss. Despite the Dietitian's recommendation for an albumin level check due to the weight loss, there was no order for the test, and the last lab work was done months prior. The LPN and RD both failed to follow up on the recommendation, and the IDT was not informed of the resident's condition. Similarly, Resident #57, who had leukemia and intact cognition, experienced significant weight loss without a re-weigh being conducted. The Dietitian confirmed that the resident should have been re-weighed but was not, and the Nurse Practitioner (NP) was not informed of the weight loss. The facility's policy on weighing residents was not followed, and there was a lack of communication and documentation regarding the residents' nutritional status and weight changes. The facility management did not respond to the survey team's findings and concerns.
Failure to Maintain Respiratory Equipment and Obtain Physician's Order
Penalty
Summary
The facility failed to maintain the necessary care and maintenance of respiratory equipment and provide a physician's order for respiratory care for a resident. The surveyor observed that the nebulizer mask and tubing for the resident had not been changed since 3/11/24, despite the facility's policy requiring weekly changes. The resident, who had a history of pneumonia, COPD, and lung cancer, was observed using the therapy gym without difficulty breathing but later reported feeling tired and having difficulty breathing after therapy. The RN confirmed that the tubing had not been changed as required and stated that an order would be obtained immediately. Further review of the resident's records revealed that there had been no physician's order for tubing changes for over nine weeks. The resident's medical diagnoses included pneumonia, centrilobular emphysema, COPD, and lung cancer. The facility's policy required that oxygen and nebulizer tubing be dated upon opening and changed weekly, which was not adhered to in this case. The DON acknowledged the oversight during a meeting with the survey team, confirming that the tubing should have been changed weekly as per the facility's policy.
Failure to Remove Expired Controlled Drug and Document Administration Accurately
Penalty
Summary
The facility failed to provide pharmaceutical services in accordance with professional standards by not removing an expired controlled drug, Lorazepam gel, from active inventory after its expiration date of 1/22/24. This deficiency was identified during a medication storage inspection where the surveyor, along with an LPN, found an expired Lorazepam gel syringe in the medication cart. The LPN acknowledged that the medication should have been removed and stated that controlled drug inventory counts were completed every shift, but the expiration date was not checked during these counts. Further review revealed discrepancies between the Individual Patient's Controlled Drug Record (IPCDR) and the electronic medication administration record (EMAR), indicating that the expired medication was still being documented as administered after its expiration date. The medical record for the resident involved showed a diagnosis of dementia with agitation and anxiety disorder, with a physician's order for Lorazepam gel to be administered as needed for agitation/anxiety. Despite this, there was no documentation in the EMAR for January and February indicating that the Lorazepam gel was administered, and only one entry in March. The LPN confirmed that the IPCDR should correspond with the EMAR for the dates and times the controlled drug was removed from inventory and administered, but this was not the case. The Director of Nursing (DON) also acknowledged the discrepancies and stated that the EMAR and electronic progress notes (EPN) should match the IPCDR. The Consultant Pharmacist (CP) confirmed that unit inspections were completed monthly and any expired medications found should be reported to nursing for removal. However, the unit inspection reports for January, February, and March did not document the expired Lorazepam gel. The facility's policies for medication administration and controlled drugs required proper documentation and removal of expired medications, but these procedures were not followed, leading to the deficiency.
Failure to Accurately Document Medications and Immunizations
Penalty
Summary
The facility failed to follow professional standards and practices to accurately document in the medical record an ordered medication a resident was being administered. For Resident #377, the surveyor identified discrepancies in the electronic medical record (EMR) where the documentation did not accurately reflect the insulin the resident was receiving. Specifically, there were six instances where the records incorrectly documented the type of insulin administered, showing Humalog instead of Lantus. The discrepancies were noted in various physician and nurse practitioner notes over several months. The facility administration attributed the errors to human error without providing further evidentiary information. For Resident #57, the surveyor found that the electronic medical record did not accurately document the resident's immunization status. Although the resident had received the influenza and pneumococcal vaccines outside the facility, this information was not recorded in the immunization tab of the EMR. The surveyor's inquiry led to the Director of Nursing (DON) updating the immunization records after obtaining information from the resident and their family. The failure to maintain accurate immunization records was noted as a deficiency.
Failure to Complete Significant Change in Status Assessment
Penalty
Summary
The facility failed to ensure that a Significant Change in Status Assessment (SCSA) was completed for a resident who experienced significant changes in their health status. The resident, who had diagnoses including essential hypertension, osteoarthritis, glaucoma, type 2 diabetes mellitus, and dementia, was observed in a geri chair with eyes closed and covered with a blanket. The resident's comprehensive Minimum Data Set (cMDS) assessment on 12/13/23 revealed a severely impaired cognitive status, significant weight loss, and the presence of an unstageable deep tissue injury (DTI) that was not present in the previous quarterly MDS (qMDS) dated 9/14/23. Despite these significant changes, the facility did not complete an SCSA as required by the Resident Assessment Instrument (RAI) Manual guidelines, which mandate an SCSA when there are major declines or improvements in a resident's status that impact more than one area of health and require interdisciplinary review and care plan revision. The surveyor's review of the resident's medical records showed a weight loss of 5% or more in the last month and the development of a DTI to the left medial heel. The MDS Coordinator (MDSC) acknowledged that the 12/13/23 cMDS should have been an SCSA but stated it was probably a mistake. The facility management, including the Licensed Nursing Home Administrator (LNHA), Director of Nursing (DON), Infection Preventionist Nurse (IPN), and Clinical Nurse Consultant (CNC), were notified of the findings and concerns but did not respond to the survey team's concerns. The failure to complete the SCSA as required by the RAI Manual constitutes a deficiency in the facility's assessment and care planning processes.
Failure to Timely Assess Fall Risk for Resident
Penalty
Summary
The facility failed to maintain professional standards of clinical practice by not assessing the fall risk for a resident at risk for falls according to their policy. Resident #63, who had severe cognitive impairment and a history of falls, did not have a quarterly Fall Risk Evaluation completed on time. The last documented Fall Risk Evaluation was dated 11/1/23, and the next one was due on 2/1/24 but was not completed until after surveyor inquiry on 3/21/24. The surveyor was unable to view the 11/1/23 evaluation in the electronic medical record, and the 2/1/24 evaluation was created retroactively on 3/21/24 after the surveyor's request. During interviews, the LPN and DON confirmed that fall risk assessments should be done on admission and quarterly. The DON acknowledged that the 2/1/24 Fall Risk Evaluation should have been completed prior to the surveyor's inquiry. Additional fall risk evaluations provided by the facility, dated 12/23/23 and 3/23/24, were also created retroactively in March 2024. The facility's policy on fall risk assessments, revised on 3/20/24, states that all residents should be assessed for fall risk on admission and reassessed quarterly in conjunction with their MDS evaluation or in the event of a change in status. The surveyor's review of the facility's documentation and interviews with staff revealed that the required fall risk assessments were not completed in a timely manner, leading to a deficiency in maintaining professional standards of clinical practice. The facility did not provide any additional information to address the deficiency identified during the survey.
Failure to Administer Pneumococcal Vaccine
Penalty
Summary
The facility failed to offer a pneumococcal vaccine to a resident, identified as Resident #63, who was admitted with diagnoses including anemia, muscle weakness, and dementia. The resident's medical record indicated a severely impaired cognitive status with a BIMS score of 03 out of 15. Despite the resident's immunization record showing a request for the pneumococcal vaccine, there was no documentation of the vaccine being administered or a historical record of it being given. The resident's consent form for the pneumococcal vaccine was signed by the resident's representative, but no date was provided next to the signature, and the vaccine was not administered until after the surveyor's inquiry. Interviews with facility staff, including an LPN, the DON, and the IP, revealed that the process for verifying and administering the pneumococcal vaccine was not followed correctly. The LPN stated that proof of vaccination should be requested, and if not available, an order from the physician should be obtained to administer the vaccine. The DON acknowledged that the vaccine should have been offered and given but was unsure why it was not. The facility's policy required that all residents be offered immunizations upon admission and reviewed quarterly, but this procedure was not adhered to in the case of Resident #63.
Latest citations in New Jersey
A resident with severe cognitive impairment, multiple comorbidities, and a stage 4 sacral pressure ulcer required staff assistance with ADLs and had a care plan specifying turning, repositioning, offloading, limited sitting time, and use of a ROHO cushion. While Documentation Survey Reports showed recorded interventions such as skin observation and turning/repositioning from January through March, the facility could not produce any ADL or POC documentation for turning, repositioning, or getting the resident out of bed for the preceding several months. CNAs, an LPN, and the DON reported that these interventions were performed and documented in the POC or progress notes, but the requested records for that time period were unavailable, contrary to facility policies on turning/repositioning and pressure injury prevention that require such care to be implemented and documented.
The facility failed to maintain sufficient kitchen staffing, resulting in days when no cook was on duty and the Food Service Director had to cover all meals. On one such day, residents reported receiving only cold items for all three meals, including cereal and milk for breakfast, cold cut sandwiches and chips for lunch, and cold cut ham wraps for dinner, with no cooked foods or vegetables provided. A Dietary Aide confirmed that both the scheduled cook and the FSD were ill that day, and the RD instructed use of only non-cook items, later acknowledging the meals did not meet daily nutritional requirements. Review of the monthly schedule showed only one cook on staff, with the FSD covering most cooking duties and no backup cooks despite the facility’s policy requiring nutritionally adequate meals even when a scheduled cook is absent.
A resident with dementia, psychotic disorder, seizures, and moderate cognitive impairment was hospitalized for anemia and AKI, where imaging revealed an acute displaced left femur fracture with associated hemorrhage, along with clinical findings of left leg swelling, redness, and tenderness. After being notified by a hospital RN of the fracture, facility leadership conducted an internal investigation, concluded there was no harm done in the facility, and remained unsure where or how the fracture occurred. The LNHA acknowledged that the cause of the injury was unknown, and the CEO confirmed that such an injury of unknown origin should be reported to the Department of Health. Despite a written abuse policy requiring immediate notification to the state and written follow-up within 72 hours when investigating possible abuse or neglect, the facility did not report this injury of unknown origin to the New Jersey Department of Health.
A resident with schizoaffective disorder, major depression, and a documented history of elopement risk had a Wander Guard in place and a care plan calling for frequent monitoring due to active exit-seeking. After the resident’s behaviors escalated, one-to-one monitoring was started but then discontinued when the resident was moved to a secured unit, where policy required controlled exit access. On an evening in question, staff on the secured unit allowed residents to leave unaccompanied to a soda machine on another unit, and the resident was last seen in their room around 9 p.m. By about an hour later, staff discovered the resident missing, and a nurse on another floor, not the secured unit staff, activated a Code Grey after hearing a door alarm. A subsequent head count confirmed the resident had left the building; the resident later stated they exited through a unit door, took an elevator to the front entrance, and used public transportation to visit a family member, demonstrating a failure to maintain a safe secured environment and adequate supervision to prevent elopement.
A resident with severe intellectual disabilities, obstructive and reflux uropathy, and an indwelling catheter was seen by a urologist, who recommended cystoscopy, laser lithotripsy of a bladder stone, and TURP, with a future OR schedule. Nursing documentation noted the recommendation, but there was no evidence in the EMR that staff followed up with the urologist or the physician to schedule the procedures. Central supply staff, responsible for scheduling, reported making weekly calls and tracking them on paper that was not retained and had no EMR access, and leadership confirmed there was no policy for scheduling out-of-facility appointments and no completed follow-up form because the urology office was expected to schedule surgery. The resident was later sent out with cloudy urine, poor intake, and lethargy and was admitted to the hospital with an obstructed Foley, bilateral hydronephrosis, and acute kidney injury, and the lack of documented follow-up conflicted with the facility’s charting policy requiring the medical record to support interdisciplinary communication.
Surveyors found that multiple residents did not receive meals and beverages as listed on their tray tickets, including missing biscuits, condiments, and diet sodas, as well as incorrect items such as apple products despite a documented "no apple" order and food preferences like "no gravy" not being honored. Residents with conditions such as protein-calorie malnutrition, DM, CKD, and other chronic diagnoses had care plans directing staff to provide diets as ordered and honor food and beverage preferences, yet trays frequently did not match tray cards. Kitchen staff acknowledged running out of certain items, and leadership confirmed that trays and tray tickets were expected to match and that meals should follow documented preferences.
A resident with multiple medical conditions and moderate cognitive impairment required substantial assistance with toileting and was care planned for incontinence management and skin integrity. Facility records showed that required documentation of bladder continence, bowel continence, bowel movements, and toilet use was missing on multiple shifts, with no related entries in progress notes. CNAs, who were responsible for providing and documenting toileting and incontinence care in the EMR, and nursing leadership confirmed that all care should be documented and verified by supervisors, yet a CNA reported sometimes forgetting to chart when busy. This failure to follow the facility’s documentation policy resulted in an incomplete and inaccurate medical record.
A resident with dementia, depression, mixed anxiety disorder, and severely impaired cognition, who depended on staff for ADLs and communicated via written questions due to hearing impairment, reported that a male CNA had touched them inappropriately in the groin while providing a shower and that they had informed staff or the administrator shortly thereafter. The resident’s care plan was later updated to prohibit male CNAs, and documentation showed showers were provided by a male CNA on several occasions. The facility conducted an internal investigation and concluded there was no evidence to support sexual abuse, but did not notify the NJDOH as required by its abuse/neglect policy and state regulations, a failure confirmed by the DON and administrator during surveyor interviews.
A cognitively intact resident with mental health diagnoses reported that a CNA pushed them to the floor when they entered another resident’s room after hearing yelling, later seeking ED care where an abrasion of the upper extremity and a visit reason of battery were documented. An LPN documented hearing yelling, seeing the resident grabbing the CNA’s arm, and calling 911, while the CNA stated the resident aggressively grabbed her and denied assaulting the resident. Despite the resident’s repeated written complaints to the DSS and LNHA alleging assault and expressing anger when seeing the CNA, the facility did not follow its abuse policy requiring temporary suspension of employees under investigation, did not promptly obtain statements from other staff or residents on the CNA’s assignment, and allowed the CNA to continue working regular shifts, including on the unit where the resident resided.
A cognitively intact resident with psychiatric diagnoses reported that a CNA pushed them and knocked them down, after which an LPN heard yelling, entered the room, saw the resident grabbing the CNA’s arm, and then called 911 and notified the nursing supervisor. The resident requested hospital transport to document injuries and was treated in the ED for an abrasion of the upper arm and given a Tdap injection. The nursing supervisor was informed of the incident, and staff later received education on abuse and neglect policies; however, there was no evidence that the allegation of staff-to-resident physical abuse was reported to the state health department, and the ADON indicated she believed it was a resident-to-staff incident rather than a reportable staff-to-resident allegation.
Failure to Maintain ADL and Turning/Repositioning Documentation for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain documentation of Activities of Daily Living (ADL) tasks, specifically getting a resident out of bed and providing turning and repositioning, for a defined period. A resident with multiple complex medical conditions, including severe protein-calorie malnutrition, gastrointestinal hemorrhage, type 2 diabetes mellitus, dysphagia, a stage 4 sacral pressure ulcer, gastrostomy status, functional quadriplegia, iron deficiency anemia, and generalized muscle weakness, was assessed as having severely impaired cognition (BIMS score of 00) and requiring staff assistance with ADLs. The resident’s care plan, initiated in September 2025 and revised in March 2026, identified moisture-associated skin damage to the sacrum related to incontinence, immobility, poor cognition, peripheral vascular disease, and diabetes, and included interventions such as turning and repositioning, offloading per policy, limiting sitting time, use of a ROHO cushion, and treatment per physician orders. Review of the resident’s Documentation Survey Reports (DSRs) from January 2026 to March 2026 showed recorded interventions and tasks including skin observation, turning and repositioning, and amount eaten, with the DSR reflecting the days these tasks were performed. However, the facility was unable to produce any DSRs or other documentation of ADL tasks for September 2025 through December 2025, despite staff interviews indicating that turning, repositioning, and getting the resident out of bed were performed and documented in the Point of Care (POC) system or skilled progress notes. The DON stated that turning and repositioning were documented by CNAs in the POC and that the resident was turned and repositioned every two hours or more frequently, but could not provide more than one month of ADL task sheets, citing a recent program change. This lack of documentation occurred despite facility policies on Turning and Repositioning and Pressure Injury Prevention and Management that require implementation and documentation of turning and repositioning for residents at risk of or with existing pressure injuries.
Insufficient Kitchen Staffing Led to Inadequate Meals
Penalty
Summary
The deficiency involves insufficient staffing in the food and nutrition services, resulting in the inability to safely and effectively carry out food service operations. During a Resident Council meeting, five of six alert and oriented residents reported that on one day the prior week there was no cook on duty and they were served cold food for all three meals. They stated that breakfast consisted of cereal and milk passed from a cart. On another day of survey observation, the Food Service Director (FSD) was observed preparing lunch and confirmed there was no cook on duty that day, so he was covering all meals himself. A Dietary Aide reported that on the day in question the scheduled cook called out sick and the FSD was also ill, leaving no cook available. The Registered Dietician (RD) was notified and instructed the Dietary Aide to use only items that did not require cooking, resulting in breakfast of cold cereal, milk, and juice; lunch of cold cut sandwiches and chips; and dinner of cold cut ham wraps, with no cooked items or vegetables provided. The RD later acknowledged that these meals did not meet daily nutritional requirements. Review of the March kitchen schedule showed only one cook scheduled for the month, with the FSD covering most cooking duties, including all breakfasts and all meals on certain days, and no backup cooks available after two cooks had quit. The facility’s own Dietary Emergency Staffing policy requires provision of safe, sanitary, and nutritionally adequate meals even in the absence of a scheduled cook, with the Administrator responsible for oversight and regulatory compliance.
Failure to Report Injury of Unknown Origin to State Authorities
Penalty
Summary
Surveyors determined that the facility failed to report an injury of unknown origin to the New Jersey Department of Health after a resident was found to have a left femur fracture. The resident had dementia with behavioral disturbances, a psychotic disorder with hallucinations, seizures, and chronic candidiasis, and was assessed on a recent MDS as moderately cognitively impaired with a BIMS score of 9/15. On 3/19/26, a hospital RN notified the facility that the resident, who had been admitted to the hospital with anemia and acute kidney injury, was also found to have left leg swelling, redness, and tenderness, and that a CT scan showed a left femur fracture. A facility document titled "Conclusion Summary of Investigation" described an acute displaced fracture of the left femur with a large adjacent hemorrhage and areas suspicious for active bleeding. During an interview, the LNHA stated that after being notified by the hospital of the fracture, the facility conducted an investigation and concluded there was no harm done in the facility, and that she was unsure where the fracture occurred, suggesting it may have happened during transfer to or at the hospital. When questioned about protocol for injuries of unknown origin, the LNHA acknowledged that the facility did not know how the injury occurred. In a separate interview, the President/CEO confirmed that an injury of unknown origin is supposed to be reported to the Department of Health and agreed that the resident’s fracture would be considered such an injury. The facility’s abuse policy, revised 1/1/2025, states that the New Jersey Department of Health and Senior Services must be called immediately to report that the facility is investigating an allegation of abuse or neglect, with written confirmation of the investigation results to follow within 72 hours. Despite this policy, the injury of unknown origin was not reported to the Department of Health.
Failure to Prevent Elopement From Secured Unit for Known High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe environment and provide adequate supervision to prevent the elopement of a resident who was a known elopement risk. The resident had been identified as high risk for elopement since admission in 2024 and had a Wander Guard device in place. An Elopement/Wandering Risk Evaluation completed on 03/04/2026 documented a history of actual or attempted elopement, verbal expressions of wanting to go home, and exit-seeking behavior, as well as cognitive impairment with poor decision-making skills. The resident’s care plan, initiated in 2024 and revised in 2025, identified the resident as an elopement risk and wanderer with a Wander Guard on the ankle and called for monitoring of behaviors and frequent monitoring due to active exit-seeking. In early March 2026, the resident’s behavior escalated. On 03/03/2026, the resident requested transfer to a facility closer to a family member after that family member had reduced the frequency of visits. On 03/04/2026, the resident attempted to leave the floor and was hard to redirect, leading the facility to place the resident on one-to-one monitoring while awaiting a secured unit bed. The resident was then transferred to a secured third-floor unit on 03/04/2026, and the one-to-one monitoring was discontinued. Facility policy on safety and supervision stated that resident supervision is determined by assessed needs and that supervision may need to be increased with changes in mental status or behaviors. The Code Grey/Elopement policy emphasized controlling exit access on secured units, including the use of door codes to leave the unit. On the evening of 03/08/2026, the resident was observed on the secured unit by staff around 9:00 PM. One LPN reported last seeing the resident at about that time when providing a snack, after which the resident went to their room; a CNA also saw the resident in the room on the phone at 9:00 PM. Staff on the secured unit stated that residents there were allowed to go off the unit unaccompanied to a soda machine on another unit, despite the resident’s elopement risk and Wander Guard. Around 10:00 PM, staff discovered the resident was no longer in the room and could not be found on the unit. Staff on the secured unit reported not hearing any door alarm sounding prior to the activation of a Code Grey, and they did not initiate the Code Grey themselves. A nurse on another floor heard a door alarm at about 10:00 PM and activated Code Grey, after which a head count revealed the resident was missing from the building. The resident later reported having exited the secured unit through an exit door, taken the elevator to the front entrance, left the building while still wearing the Wander Guard, and used public transportation to travel to a family member’s home, where police subsequently located the resident. These events led surveyors to determine that the facility failed to maintain a safe environment on the secured unit with adequate supervision to prevent elopement, resulting in an Immediate Jeopardy finding under F689.
Removal Plan
- The DON and ADON provided immediate in-service training and began reeducation regarding safety and protocols for residents at risk for wandering and elopement.
- Upon the resident’s safe return, the resident was reassessed.
- A new Wander Guard with a secure band was placed on the resident’s ankle.
- The resident’s room was moved adjacent to the nurses’ station for monitoring.
- The resident was placed on 1:1 monitoring for all shifts.
- The DON and ADON provided facility staff education on the importance of monitoring residents’ doors on secure units to prevent residents from exiting.
- The DON and ADON in-serviced all staff on monitoring doors on secured units to prevent unauthorized exits.
- The DON and ADON in-serviced all staff that residents living on secured units need to be escorted by staff members when leaving the unit.
- Testing of all door alarms and door locks was completed and confirmed working as designed by Northeast Protection Partners.
- The Wander Guard installer completed testing of all Wander Guard alarms and magnetic locks and confirmed they are working as designed.
- A trained staff member will be stationed on all shifts in the hallway of the secured unit to supervise doors and prevent unauthorized exit by all residents living on that unit.
- All staff who work on the secured units were in-serviced by the DON and ADONs on monitoring doors on secured units to prevent unauthorized exits.
Failure to Document and Follow Up on Urology-Ordered Catheter-Related Procedures
Penalty
Summary
The deficiency involves the facility’s failure to provide timely follow-up management and care for a resident with an indwelling catheter after a urology consultation. The resident was admitted with obstructive and reflux uropathy, congenital malformation of the urinary system, and severe intellectual disabilities, and was dependent on staff for toileting with an indwelling catheter in place. A urology visit summary documented that the resident was to be scheduled for cystoscopy, laser lithotripsy of a bladder stone, and a transurethral resection of the prostate. Nursing notes indicated that the resident returned from the urology appointment with a recommendation for a future operating room schedule. However, there was no documented evidence in the electronic medical record that the facility followed up with the urologist or contacted the resident’s medical doctor regarding scheduling these procedures. Subsequently, the resident was admitted to the hospital with an obstructed Foley catheter, bilateral hydronephrosis, and acute kidney injury, and prior nursing documentation noted cloudy yellow urine, poor intake, and lethargy with an order to send the resident out for further evaluation. Interviews revealed that central supply staff, who were responsible for scheduling appointments, stated they called the urology office weekly but did not have access to the EMR and kept paper logs of attempts that were not retained. The infection preventionist, LNHA, and ADON acknowledged that there was no facility policy for scheduling out-of-facility appointments, that the process relied on central supply’s undocumented personal log, and that no consult follow-up form was completed because the urology office was expected to schedule the surgery. The facility’s charting documentation policy stated that the medical record should facilitate communication between the interdisciplinary team, but there was no documentation of follow-up attempts or escalation when the procedures were not scheduled.
Failure to Provide Meals Consistent With Diet Orders and Documented Preferences
Penalty
Summary
The deficiency involves the facility’s failure to consistently provide meals and condiments in accordance with residents’ diet orders and documented food preferences as listed on tray tickets. During a breakfast observation, one resident reported missing items from their tray; review of the tray and ticket showed the resident did not receive a biscuit, pepper packet, or ketchup packet, despite these items being ordered. This resident had diagnoses including protein-calorie malnutrition, type 2 diabetes mellitus, and hypertension, and was on a no added salt, consistent carbohydrate diet with a care plan intervention to provide and serve diet as ordered. Another resident, observed eating breakfast in bed, reported both missing and incorrect items. The tray ticket called for a fruit cup, cranberry juice, a biscuit, salt, pepper, and ketchup, but these were not all present; instead, the resident received applesauce and apple juice, which were not on the ticket, and the ticket specifically indicated no apple products. On a subsequent breakfast observation, the same resident’s tray again lacked the ordered salt, pepper, and cranberry juice and instead contained apple juice, despite an order specifying no apple and an allergy to peach skin. This resident’s care plan included an intervention to provide food and beverage preferences. During a kitchen interview, the cook acknowledged not making enough biscuits and could not explain why condiments were missing. Additional residents experienced similar issues during lunch observations. One resident reported that a can of diet ginger ale listed on the lunch ticket was not provided, despite a care plan intervention to honor food preferences. Another resident stated they were given the wrong vegetable; chopped carrots were served instead of the chopped oriental vegetables listed on the tray ticket, even though the care plan directed staff to provide and serve diet as ordered and honor food preferences. A further resident reported receiving gravy on both roast pork and mashed potatoes when the tray ticket documented a preference for no gravy, despite a care plan intervention to honor food preferences. The Food Service Director and DON both stated that tray tickets and meal trays should match and that meals should be consistent with residents’ preferences as indicated on the tray cards, but were unable to explain the missing condiments.
Failure to Maintain Complete and Accurate Toileting and Continence Documentation
Penalty
Summary
The facility failed to maintain an accurate and complete medical record for a resident with diagnoses including a cervical vertebra fracture, heart failure, and type II diabetes. The resident’s comprehensive MDS showed a BIMS score of 12/15, indicating moderate cognitive impairment, and documented that the resident required substantial assistance with toileting hygiene and toilet transfer. The care plan identified the resident as being at risk for skin breakdown, having incontinent episodes, and having a self-care performance deficit, with interventions such as routine incontinence checks, offering toileting every 2–3 hours, keeping the skin clean and dry, and providing one-person assistance for toileting and all transfers. The Documentation Survey Report for January specified that bladder continence, bowel continence, bowel movements, and toilet use were to be documented each shift. Record review showed missing documentation for multiple dates and shifts for bladder continence, bowel continence, bowel movements, and toilet use, with no corresponding entries in the progress notes to account for this care. Interviews with the LPN Unit Manager, a CNA, the DON, and the LNHA confirmed that CNAs were primarily responsible for providing toileting and incontinence care and were expected to document all care in the EMR, and that supervisors were responsible for verifying that documentation was completed. The CNA interviewed acknowledged sometimes forgetting to document care when busy. The facility’s charting and documentation policy required that all services provided to residents be documented completely and accurately, including treatments or services performed, which was not followed in this case, resulting in incomplete medical records for the resident.
Failure to Report Allegation of Sexual Abuse to State Authorities
Penalty
Summary
The facility failed to report an allegation of sexual abuse to the New Jersey Department of Health (NJDOH) as required by regulation and its own abuse/neglect policy. A resident with diagnoses including dementia, depression, and mixed anxiety disorder, and with severely impaired cognition per the most recent MDS, was dependent on staff for ADLs such as toileting hygiene, showering, and lower body dressing. During a surveyor interview conducted using written questions due to the resident’s hearing impairment, the resident stated they preferred only female CNAs to provide care and reported that a few months earlier a male CNA, whose name sounded like a specific individual, had touched them inappropriately in the groin area while giving a shower. The resident indicated they had reported this incident to either someone who changed them or to the administrator on or shortly after the day it occurred. The resident’s care plan, revised at a later date, included an intervention specifying no male CNAs, and point-of-care documentation showed the resident received showers on multiple dates, which the DON identified as having been provided by a specific male CNA. The facility initiated an internal investigation, including interviews, staff statements, and record reviews, and concluded there was no evidence to support the allegation of sexual abuse. However, the investigation file contained no documentation that the NJDOH was notified of the allegation. In interviews, the DON described the facility’s process for handling abuse allegations, including reporting to NJDOH within specified time frames if an event is deemed reportable, and the administrator acknowledged that the allegation should have been reported to NJDOH but was not. The facility’s written policy required immediate notification (as soon as possible but not to exceed 2 hours) to the Department of Health and Senior Services and the Office of the Ombudsman for residents 60 or over, followed by a written report within 5 days, which was not followed in this case.
Failure to Remove Alleged Perpetrator and Fully Investigate Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from alleged abuse by a CNA and failure to implement its abuse policy after learning of the allegation. A cognitively intact resident with diagnoses including Bipolar Disorder, Anxiety Disorder, and Major Depressive Disorder reported that a CNA pushed them, causing them to fall, when they entered another resident’s room after hearing yelling and crying. An ED after-visit summary documented that the resident was seen for battery and diagnosed with an abrasion of the left upper extremity. The facility’s own abuse/neglect policy stated that employees under investigation would be temporarily suspended until the Administrator reviewed the results of the investigation, but this was not followed for the CNA involved. On the date of the incident, an LPN documented that they heard yelling from another resident’s room and, upon entering, observed the resident yelling and grabbing the CNA’s left upper arm. The LPN reported asking the resident to leave the CNA alone, then leaving the room to notify the Nursing Supervisor and call 911. The CNA’s written statement asserted that the resident grabbed her in an aggressive manner to cause physical harm and that she did not assault the resident. The facility administration later reviewed video footage and statements from the CNA and the LPN and concluded there was no merit to the resident’s accusatory statement, citing the resident’s mental health history, and asked the CNA to return to her scheduled shift. On multiple occasions following the incident, the resident sent emails to the Director of Social Services and the LNHA stating that the CNA had assaulted them and expressing distress that the incident was not addressed. Despite these communications, the facility did not obtain statements from other staff members beyond the alleged perpetrator, the LPN, and the Nursing Supervisor, and did not interview or obtain statements from other residents typically on the CNA’s assignment until after the surveyor requested investigation documents. Payroll and assignment records showed that the CNA continued to work regular shifts, including on the behavior unit where the resident lived, both immediately after the incident and after the resident’s written allegation of assault. Facility staff, including the DSS, LNHA, and ADON, acknowledged the resident’s ongoing anger when seeing the CNA on the unit and referenced the resident’s history of aggressive and explosive behavior, but the facility did not remove the CNA from resident care or from the resident’s unit in accordance with its abuse policy when the allegation was reported.
Removal Plan
- Resident #1 had a follow up consultation with the Statewide Clinical Outreach Program for the Elderly (S-COPE)
- ADON conducted abuse policy re-education for nursing staff post incident
- The Administrator and the ADON were re-educated on the Abuse Policy and Procedure and Federal deficiency F600 (free from abuse and neglect) by the President of Clinical Services
- The ADON and the Regional Nurse Consultant provided 1:1 re-education on the Abuse Policy to the Registered Nurse Supervisor involved in the incident
- ADON began facility-wide education for all staff on the Abuse Policy to protect all residents from abuse
- Unit managers and Nursing Supervisors were re-educated by ADON on the Abuse Policy and the requirement to report
- The Social Worker conducted additional interviews on the two units assigned to the CNA
Failure to Report Alleged Staff-to-Resident Physical Abuse to State Authorities
Penalty
Summary
The facility failed to report to the New Jersey Department of Health an allegation of physical abuse involving a resident and a CNA. The cognitively intact resident, with diagnoses including Bipolar Disorder, Anxiety Disorder, and Major Depressive Disorder, reported that a CNA pushed them and knocked them down. A behavior note documented that an LPN heard yelling and shouting in another resident’s room where the CNA was providing care, and when the LPN entered, the resident was observed grabbing the CNA’s arm. The LPN then exited the room to call 911 and notify the nursing supervisor. A facility event summary indicated that the resident called 911 and requested transport to the hospital to document injuries allegedly sustained from being physically assaulted by the CNA. Emergency department records showed the resident was treated for an abrasion of the left upper arm and received a Tdap injection. A nursing supervisor’s witness statement documented that she was made aware of an incident between the resident and the CNA. Facility documents showed that staff were in-serviced on abuse and neglect policies and procedures following the incident, but there was no evidence that the allegation of abuse was reported to the New Jersey Department of Health. During an interview, the ADON stated that the facility would notify the Department of Health for alleged abuse, major injury, and staff-to-resident abuse, but indicated she believed this incident was considered a resident-to-staff incident rather than a staff-to-resident allegation, and thus it was not reported as required.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release May 27, 2026) and official state health department websites — never guesswork.
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