Below average — CMS composite of the measures below.
A standard survey is most likely before 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 Cranford Park Care during CMS and state inspections, most recent first.
A resident with hemiplegia, DM2, and convulsions was admitted with an order for IV Vancomycin for infection, but the medication was not properly reconciled at admission and was not given when ordered. The admitting LPN expected the next shift to complete reconciliation, the order was not entered into the computer, the pharmacy delivery was delayed, and the first documented dose was not administered until the following day.
A resident with an ileostomy, intact cognition, and orders for pouch changes, skin protection, and behavior monitoring had those care instructions missing from the MAR/TAR. Progress notes documented fidgeting with the ileostomy bag and other related behaviors, but the MAR did not show the behaviors, non-drug interventions, or outcomes, and the DON stated the treatment orders should have been transcribed and documented.
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.
Dust was observed on the kitchen ceiling above the tray line, including dust hanging in strings over clean plates, open trays, the serving line, and uncovered cheese. A Dietary staff member also wore the same gloves while touching non-food surfaces and then handled ready-to-eat foods, and later adjusted a beard net after donning clean gloves but continued serving with the same gloves. The DM confirmed the dusty ceiling and improper glove use during tray line service.
Uncovered garbage bins were observed near the entrance by the kitchen stairs, with a strong trash, bowel movement, and rotten food odor present on multiple observations. Three bins were left open, including a kitchen trash bin with waste piled above the rim and used gloves on the ground nearby. The DM and MD confirmed the bins were not covered, and the Administrator stated there was no waste disposal policy.
Pureed Menu Not Followed Dietary staff did not follow the written pureed menu for several residents. During tray line observation, an aide served 3-oz portions instead of the 4-oz portions listed on the menu, and on another meal served a pureed rigatoni and sausage entree without the tomato sauce called for, topped it with white cheese sauce, and did not include the pureed bread. The DM confirmed the portions and recipe were not correct and stated the recipe should have been followed.
Staff failed to follow infection control practices for a resident on droplet precautions, a resident on EBP for a chronic wound, and another resident during wound care. PPE was not fully available at the COVID-19 resident’s room, a CNA entered that room wearing only a mask, a CNA provided high-contact care to a resident with a pressure ulcer without a gown, and an LPN and staffing coordinator did not use gowns during wound care and did not perform hand hygiene between glove changes.
Failure to Include Resident in Care Plan Meetings: A resident with dementia, depression, and type II DM had a BIMS score indicating cognitive intactness, yet the EMR contained no documentation that she was invited to or attended her care plan meetings. The resident and family denied any participation, while the SSD stated invitations were given but not documented or retained.
Failure to Provide Written Advance Directive Information: The facility did not document that two residents or their representatives received written information about the right to accept or refuse medical or surgical treatment and to formulate an advance directive. EMR review showed no Advance Directive documentation for either resident, and the SSD stated the facility uses the POLST form and does not provide information on how to formulate an AD.
Two residents transferred to the hospital received transfer notices that listed the reason for transfer and Ombudsman contact information, but did not include appeal rights, how to file an appeal, or appeals agency contact information. One resident had discitis, and the other had malnutrition, heart disease, type II DM, a pacemaker, and severe cognitive impairment. The SSD and Administrator stated they were not aware the transfer notice needed to include the required appeals information.
MDS Did Not Reflect Stage III Sacral Pressure Ulcer: The facility failed to code a resident’s stage III sacral pressure ulcer on the MDS even though the care plan, wound consults, and TAR documented the wound and ongoing treatment. The resident had dementia, aphasia, depression, anxiety, and chronic pain, and the MDSC stated the ulcer was missed despite documentation showing it was present during the MDS lookback period.
Failure to provide ordered pressure ulcer prevention measures: A resident with dementia, severe cognitive impairment, and high pressure ulcer risk had a stage 3 sacral ulcer and physician orders for heel booties/heel boots and a cushion pad to offload the left toes. During repeated observations, staff found the resident in bed wearing only thick socks, with no boots or toe cushion in place, and an LPN later stated the orders had not been applied even though they were still being documented as completed.
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.
Medication Reconciliation Failure Delayed IV Antibiotic Start
Penalty
Summary
The facility failed to appropriately reconcile a resident’s medications at admission and failed to administer Vancomycin in a timely manner in accordance with professional standard of practice. The resident was admitted with diagnoses including hemiplegia and hemiparesis following cerebral infarction, type II diabetes, and convulsions, and had a BIMS score of 13 out of 15, indicating intact cognition. The care plan identified IV antibiotic therapy with Vancomycin for an infection, and the After Visit Summary directed that Vancomycin 1.25 gram/250 mL in sodium chloride 0.9% be started on the day after admission. The MAR showed the medication was ordered to begin on that date, but the box for that day was marked with a 9, indicating it was not administered as ordered, and the first documented administration occurred the following day in the afternoon. Nursing notes showed that the resident arrived late in the shift and that medications were reviewed by the admitting LPN, but the Vancomycin was not entered into the computer on the start date. The next morning, a message was left for the NP asking whether the Vancomycin should continue, and later the pharmacy was contacted and said the medication would arrive in the second delivery. The LPN later documented that the order had not been entered, that she contacted the NP to obtain the order, and that she was told to obtain the medication from the backup, but she did not have access to the backup and sent the script to the pharmacy. During interview, the LPN stated she expected the next shift to reconcile the medications, while the NS and DON stated that the admitting nurse was responsible for medication reconciliation and that the resident should have started Vancomycin on the ordered date.
Failure to Document Ileostomy Care and Behavior Monitoring
Penalty
Summary
The facility failed to ensure that care and services for a resident's ileostomy were provided and failed to monitor and document the resident's behaviors related to the ileostomy in the medical record. The resident was admitted with diagnoses including encounter for attention to ileostomy, need for assistance with personal care, long-term use of immunosuppressive biologic medication, dependence on renal dialysis, and heart transplant status. The resident's MDS indicated intact cognition with a BIMS score of 15 out of 15 and that partial or moderate assistance was required for ostomy hygiene. The care plan identified anxiety related to fear of ileostomy leakage and ostomy supply availability, and physician orders directed that the ileostomy bag be changed every three days and as needed, with specific pouching system instructions and skin protection measures. Additional orders directed staff to monitor target behaviors related to use of alprazolam, including crying, fidgeting with the ileostomy, inability to sleep, and restlessness, and to complete monthly psychotropic medication reviews. Review of the MARs and TARs for January, February, and March 2026 showed that the ileostomy bag change orders and ileostomy care instructions did not appear on the MARs or TARs. Progress notes documented behaviors directed toward the ileostomy bag on multiple dates, but the February and March MARs did not document any behaviors, non-drug interventions, or outcomes related to those events, and there was no evidence of staff interventions to address the behaviors. The DON stated that the pouch system changes should have been documented on the MARs or TARs, that treatment orders should have been transcribed by the nurse who received the order, and that touching and fidgeting with the ileostomy bag documented in progress notes should have been documented in the behavior monitoring section of the MAR.
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.
Dusty Tray Line Ceiling and Improper Glove Use During Meal Service
Penalty
Summary
The facility failed to keep the kitchen ceiling clean above the tray line area where clean plates, open trays being prepared, the serving line, and a cart containing uncovered cheese were located. During observations on 08/18/25 and again on 08/20/25 and 08/21/25, the ceiling above the tray line was covered with gray/brown dust, including dust hanging in strings that moved in the airflow. The Dietary Manager confirmed the ceiling was dusty and acknowledged the dust had the potential to contaminate food. He stated the dust needed to be removed because the building was old, but the ceiling remained unclean during the later observation. The facility also failed to ensure adequate hand hygiene and glove use during meal service. A Dietary staff member wore the same pair of gloves throughout tray line service while touching surfaces away from the tray line, including the plate warming cart, oven knobs and handles, pan handles, a cutting board, and his pants, and then used those same gloves to handle ready-to-eat foods such as bread, noodles, green beans, and a grilled cheese sandwich. The staff member’s beard net fell below his chin, and after the Dietary Manager reminded him to wash his hands and apply new gloves, he washed his hands and donned clean gloves but then adjusted the beard net and continued serving with the same gloves. The staff member confirmed he did not change gloves after touching potentially contaminated surfaces, and the Dietary Manager confirmed he was touching ready-to-eat foods with gloved hands.
Uncovered garbage bins near kitchen entrance
Penalty
Summary
The facility failed to ensure garbage was covered in the area near the entrance to Building A next to the stairs down to the kitchen entrance. During observations on 08/18/25, 08/20/25, and 08/21/25, surveyors found three open bins containing garbage bags and noted a pervasive trash, bowel movement, and rotten food odor. None of the bins had lids during any of the observations, and on 08/21/25 the kitchen trash in one bin was piled high above the top of the bin, with a pair of used gloves on the ground next to it. During interview, the Dietary Manager stated one bin was for kitchen trash and the others were for housekeeping waste. The Maintenance Director, who also served as the director of housekeeping, stated the housekeeping trash bin was emptied into the dumpster several times each day and that the other two bins contained soiled linens for laundering. The Maintenance Director confirmed none of the bins were covered and stated the kitchen trash bin had a lid that should be used to cover the trash. The Administrator stated the facility did not have a policy addressing waste disposal.
Pureed Menu Portions and Recipes Not Followed
Penalty
Summary
The facility failed to ensure menus were followed for five residents who received a pureed diet out of a census of 69. Review of the diet assignment listing showed that residents R41, R47, R48, R2, and R79 were on pureed diets. The undated Week 1, Cycle Day 4 menu called for a pureed lunch of 8 oz of pureed goulash split into 4 oz pureed egg noodles and 4 oz pureed goulash, 4 oz of pureed green beans, and one slice of pureed garlic bread. During lunch tray line observation, Dietary staff served a pureed plate with 3-oz portions of pureed goulash, pasta, bread, and green beans. The dietary staff member confirmed he used 3-oz portions and was unaware the menu called for 4-oz portions, and the Dietary Manager confirmed the portion size was not correct. The undated Week 1, Cycle Day 5 menu called for 8 oz of rigatoni with Italian sausage, 1 slice garlic toast, and 4 oz of broccoli for the pureed diet. The recipe for rigatoni with Italian sausage called for Italian sausage, penne pasta, tomato sauce, tomato juice, mozzarella, and parmesan cheeses to be combined and served together. During lunch tray line observation, Dietary staff served a pureed rigatoni and sausage entree without tomato sauce that appeared green in color and topped it with white cheese sauce. The staff member stated he used the white cheese sauce for residents who could not have tomatoes, but the resident receiving the plate could have tomatoes, and he did not know why he served cheese sauce instead of the tomato sauce called for in the menu. He also stated he did not include bread in the pureed rigatoni and sausage mixture. The Dietary Manager stated the recipe should have been followed and residents should have received the same entree as the regular menu.
Infection Control and PPE Failures During Isolation, EBP, and Wound Care
Penalty
Summary
The facility failed to follow infection prevention and control practices for three residents during observation of droplet precautions, enhanced barrier precautions, and wound care. For a resident with COVID-19 and droplet precautions in place, the room had signage posted, but surveyors could not locate face shields or goggles outside the room before entry, and there was no receptacle available inside the room for PPE disposal. A nurse later retrieved face shields from a secured closet and restocked the drawers outside the room, and a red bin was then to be placed in the room. During a later observation, a CNA entered and exited the COVID-19 resident’s room wearing only a mask, despite the resident being on droplet precautions. For another resident with dementia, aphasia, and a chronic stage 3 sacral pressure ulcer, the care plan and orders included enhanced barrier protection for infection prevention. During observation, a CNA provided incontinence care and a bed bath while wearing gloves but not a gown, even though a sign outside the room directed staff to don a gown in addition to gloves for high-contact activities and gowns and gloves were available outside the room. The CNA stated she did not wear a gown because the resident did not have an active infection. During wound care for a third resident with enhanced barrier precautions in place, PPE was available outside the room, but the LPN did not don a protective gown before providing wound care, and the staffing coordinator did not don a gown and gloves before assisting with positioning. During the wound care, the LPN removed dirty gloves, did not sanitize or wash hands before putting on clean gloves, and repeated glove changes without hand hygiene. The LPN stated he should have worn a gown and had not been trained to use hand sanitizer or wash hands between glove changes, while the staffing coordinator stated she knew she was supposed to wear a gown but forgot.
Failure to Document Resident Participation in Care Planning
Penalty
Summary
The facility failed to allow one resident to participate in the development and implementation of her person-centered plan of care. Resident 33 was admitted with diagnoses of dementia, depression, and type II diabetes. Her quarterly MDS showed a BIMS score of 14 out of 15, indicating she was cognitively intact, and it also documented assistance needs for eating, oral hygiene, bed mobility, toileting, bathing, dressing, and personal hygiene. Review of the EMR showed care plan meetings were held for the resident on admission and during quarterly reviews, but there was no documentation that she was invited to attend or that she participated. There was also no documentation in the Progress Notes or care plan meeting records showing an invitation from the Social Service Director or any other staff member. The resident and her family member both denied ever being invited to or taking part in a care plan meeting since admission. The SSD stated the resident had been invited, but also stated the invitation was not documented in the medical record and no copy was retained.
Failure to Provide Written Advance Directive Information
Penalty
Summary
The facility failed to provide written information to two residents, R11 and R17, and/or their representatives regarding the right to accept or refuse medical or surgical treatment and to formulate an advance directive. Review of R11's admission record in the EMR showed no documentation that R11 had an Advance Directive or that the facility provided written information about these rights. Review of R17's admission record in the EMR showed the same lack of documentation for an Advance Directive or written information about the right to accept or refuse treatment and/or formulate an advance directive. During interview, the Social Services Director stated that she asks the resident or resident representative if they have an Advance Directive and discusses Advance Directives on admission, but the facility uses the POLST form. She stated that she does not provide information on how to formulate an Advance Directive and only gives the POLST form so residents can make their choices, then documents this in the progress notes. The administrator stated that the facility uses the POLST form and that the SSD discusses Advance Directives with residents and resident representatives during admission.
Transfer Notices Missing Appeal Rights Information
Penalty
Summary
The facility failed to ensure that written notice provided to residents or their representatives when transferring them to the hospital included a statement of appeal rights, instructions on how to file an appeal, and contact information for the appeals agency for two residents reviewed for hospitalization. For R73, the EMR showed admission with discitis and discharge from the facility on 05/20/25. The discharge MDS indicated transfer to a hospital, and the Acute Transfer Form completed that day included the reason for transfer, transfer location, and Ombudsman contact information, but did not include appeal rights, how to file an appeal, or appeals contact information. During interview, the SSD stated she completed the transfer form and was not aware that appeal rights and related information were required, and the Administrator stated he did not believe appeal rights were necessary on the hospital transfer form, though he understood it was a regulatory requirement. For R2, the EMR showed admission with malnutrition, heart disease, type II diabetes, and a cardiac pacemaker, and the five-day MDS showed a BIMS score of 00 indicating severe cognitive impairment. The facility’s transfer notice and bed hold policy form indicated R2 was transferred to the hospital for a hemoglobin of 6.8 gm/dL, but the notice only listed NJ Long-Term Care Ombudsman contact information if the resident or family disagreed with the transfer. It did not include a statement of appeal rights, instructions for filing an appeal, or appeals agency contact information. The progress note documented that the NP was aware of the lab result and ordered transfer to the hospital, and the NP called the resident’s son and the hospital to make them aware of the transfer. The SSD and Administrator both stated they were not aware that the transfer notice needed to include appeal rights and appeals contact information.
MDS Did Not Reflect Stage III Sacral Pressure Ulcer
Penalty
Summary
The facility failed to ensure the Minimum Data Set (MDS) accurately reflected the presence of a stage III pressure ulcer for one resident. Review of the resident’s EMR showed diagnoses including dementia, aphasia, depression, anxiety, and chronic pain. The quarterly MDS with an ARD of 07/31/25 indicated no current pressure ulcers, even though the resident’s care plan dated 05/23/25 documented a stage 3 pressure ulcer on the sacrum related to impaired mobility and incontinence, with interventions including heel booties and enhanced barrier protection for infection prevention. Record review also showed wound consultation reports dated 06/20/25, 07/18/25, and 08/01/25 documenting that the resident’s healed sacral wound had re-opened as a stage III pressure ulcer and continued to require treatment and offloading instructions. The TAR for July 2025 included physician orders for sacral wound care, including cleansing, collagen or prisma/collagen application, zinc oxide to the periwound, protective dressing, repositioning side to side, and monitoring for changes, with the treatments documented as completed. During interview, the MDS Coordinator stated she missed coding the sacral pressure ulcer because she believed there was no documentation showing it re-opened after healing, but acknowledged the paperwork showed the ulcer during the MDS lookback period and should have been coded.
Failure to Provide Ordered Pressure Ulcer Prevention Measures
Penalty
Summary
The facility failed to ensure that one resident with dementia, aphasia, depression, anxiety, chronic pain, severe cognitive impairment, and dependence on staff for all activities of daily living received physician-ordered pressure ulcer prevention measures. The resident’s care plan identified a stage 3 sacral pressure ulcer and included applying heel booties to both feet every shift, and the physician’s orders also included bilateral booties to the feet every shift and a cushion pad between the left foot toes with offloading using heel boots. The resident was assessed as high risk for pressure ulcer development and used a pressure-reducing mattress. During multiple observations, the resident was found lying in bed with thick socks on, but no heel boots or booties were visible. When staff were interviewed and the resident’s feet were observed, an LPN confirmed the resident did not have boots on and that there was no cushion pad on the left toes. A CNA also confirmed the resident was not wearing boots while in bed, and another CNA stated the resident did not have boots and did not use them. Later, an LPN stated the heel boots and cushion pad had not been applied because the resident no longer had skin issues on her foot, and could not explain why the orders were still being marked as completed on the TAR. The DON stated the thick socks were not considered booties or heel boots and confirmed the current orders still should have been implemented daily.
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.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 1,337 citations issued within 25 miles in the last 12 months — including the 20 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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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A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Cranford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Birchwood Rehabilitation And Healthcare Center | 1.1 mi | ★★★★★ | 7 | 0 |
| Complete Care At Clark Llc | 2.1 mi | ★★★★★ | 1 | 0 |
| Cornell Hall Care & Rehabilitation Center | 2.2 mi | ★★★★★ | 0 | 0 |
| Complete Care At Westfield, Llc | 2.5 mi | ★★★★★ | 0 | 0 |
| Care Connection Rahway | 2.8 mi | ★★★★★ | 12 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.