Inspection Reports for
Cranford Park Care
600 Lincoln Park East, Cranford, NJ, 07016
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
18.2 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
250% worse than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
36
27
18
9
0
Occupancy
Latest occupancy rate
64% occupied
Based on a August 2024 inspection.
Occupancy rate over time
Notice
Deficiencies: 0
Date: Nov 20, 2025
Visit Reason
This document serves to inform individuals about the privacy practices of NJDHSS, including how their medical information may be used and disclosed, and their rights related to this information.
Findings
The notice explains the types of information covered, reasons for use and disclosure of health information, individuals' rights to access and control their information, and legal duties of NJDHSS to protect privacy.
Report Facts
Effective date: 2011
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director, Office of Legal and Regulatory Compliance | Listed as NJDHSS Privacy Officer contact for questions about the notice |
Inspection Report
Deficiencies: 1
Date: Oct 31, 2025
Visit Reason
The inspection was conducted to assess the facility's compliance with maintaining a safe, clean, comfortable, and homelike environment for residents, including treatment and supports for daily living.
Findings
The surveyor observed multiple environmental deficiencies including heavily soiled and ripped carpet on stairways, dust and debris accumulation, broken exposed pipes, leaking air conditioner covers with stains, missing window treatments, and unsanitary conditions in the kitchen dumbwaiter area. Interviews with facility staff confirmed the need for cleaning and maintenance.
Deficiencies (1)
Failure to maintain the resident environment and living areas in a safe, sanitary, and homelike manner, including soiled carpets, dust accumulation, broken pipes, leaking air conditioner, missing window treatments, and unsanitary kitchen dumbwaiter area.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Food Service Director | Interviewed regarding cleaning of the dumbwaiter area. | |
| Maintenance and Housekeeping Director | Interviewed regarding environmental rounds and cleaning schedules. | |
| Licensed Nursing Home Administrator | Present during exit conference reviewing findings. | |
| Director of Nursing | Present during exit conference reviewing findings. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jun 19, 2025
Visit Reason
The inspection was conducted based on complaints NJ00182926 and NJ00179350 to investigate alleged deficiencies in care plan revisions and documentation of care provided to dependent residents.
Complaint Details
Complaint #NJ00182926 involved failure to revise care plans appropriately. Complaint #NJ00179350 and #NJ00182926 involved failure to consistently document care provided to dependent residents.
Findings
The facility failed to revise a care plan after an annual assessment for a cognitively impaired resident needing assistance with meals and failed to follow its Care Plan policy. Additionally, the facility failed to consistently document care provided to dependent residents according to facility policy and protocol for three residents reviewed.
Deficiencies (2)
Failure to revise a care plan after an annual assessment for a cognitively impaired resident requiring assistance with meals.
Failure to consistently document care provided to dependent residents according to facility policy and protocol.
Report Facts
BIMS score: 3
BIMS score: 9
BIMS score: 9
Residents reviewed for care plans: 3
Residents reviewed for documentation: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Responsible for updating care plans and ensuring documentation compliance. | |
| Assistant Director of Nursing (ADON) | Responsible for updating care plans and ensuring documentation compliance. | |
| Certified Nursing Assistant (CNA) | Responsible for providing and documenting care; stated documentation should have no blanks. | |
| Licensed Practical Nurse (LPN) | Responsible for reporting undocumented care to DON. |
Inspection Report
Complaint Investigation
Census: 64
Deficiencies: 0
Date: Aug 22, 2024
Visit Reason
The inspection was conducted as a complaint investigation based on Complaint #NJ00176097.
Complaint Details
Complaint #NJ00176097 was investigated and the facility was found to be in substantial compliance.
Findings
The facility was found to be in substantial compliance with the requirements of 42 CFR Part 483, Subpart B, for long term care facilities based on this complaint visit.
Report Facts
Sample Size: 3
Inspection Report
Complaint Investigation
Census: 61
Deficiencies: 0
Date: Jun 20, 2024
Visit Reason
The inspection was conducted as a complaint investigation based on Complaint #: NJ172933.
Complaint Details
Complaint #: NJ172933; the facility was found to be in substantial compliance based on this complaint visit.
Findings
The facility was found to be in substantial compliance with the requirements of 42 CFR Part 483, Subpart B, for long term care facilities based on this complaint visit. Additionally, the facility was in compliance with New Jersey Administrative Code, Chapter 8:39, standards for licensure of long term care facilities.
Report Facts
Sample Size: 7
Inspection Report
Routine
Deficiencies: 12
Date: Mar 27, 2024
Visit Reason
The inspection was a routine regulatory survey to assess compliance with healthcare facility regulations, including resident care, medication management, infection control, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to complete significant change assessments, late submission of Minimum Data Set (MDS) assessments, inaccurate MDS coding, failure to assess fall risk timely, delayed implementation of wound care interventions, failure to implement occupational therapy recommendations, inadequate nutritional monitoring and follow-up, improper respiratory equipment maintenance, expired medication not removed timely, inaccurate medication documentation, delayed Payroll Based Journal (PBJ) submission, and failure to offer pneumococcal vaccination to a resident.
Deficiencies (12)
Failure to complete a Significant Change in Status Assessment (SCSA) for Resident #24.
Failure to complete and submit electronically the Minimum Data Set (MDS) within 14 days for 7 residents.
Failure to accurately code the MDS for 5 residents including inaccurate vaccination status.
Failure to assess fall risk timely for Resident #63; fall risk assessments were late and created after surveyor inquiry.
Failure to implement wound care physician's recommendation timely for Resident #28; delay in wound VAC application.
Failure to implement occupational therapy recommendations and timely revise care plan for Resident #29 regarding splint use and contracture prevention.
Failure to follow through with dietitian's recommendations, ensure interdisciplinary team awareness of significant weight loss, and conduct re-weighs as per clinical standards for Residents #24 and #57.
Failure to maintain respiratory equipment and provide physician orders for respiratory care for Resident #58.
Failure to remove expired controlled medication (Lorazepam gel) timely and maintain accurate documentation for removal and administration for Resident #39.
Failure to accurately document medication orders and administration for Resident #377 regarding insulin types.
Failure to submit Payroll Based Journal (PBJ) staffing data to CMS timely for Fiscal Year Quarter 1 2024.
Failure to offer pneumococcal vaccination to Resident #63 prior to surveyor inquiry.
Report Facts
Weight loss percentage: 8
Weight loss percentage: 5.5
BIMS score: 3
BIMS score: 3
BIMS score: 0
BIMS score: 15
Expiration date: Jan 22, 2024
PBJ report quarter: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) | Named in medication removal and administration finding for Lorazepam gel | |
| Director of Nursing (DON) | Named in multiple findings including wound care, weight loss follow-up, medication documentation, and PBJ submission | |
| Licensed Nursing Home Administrator (LNHA) | Named in multiple findings including PBJ submission and medication documentation | |
| Registered Dietitian (RD) | Named in nutritional monitoring and weight loss findings | |
| MDS Coordinator (MDSC) | Named in MDS submission and vaccination documentation findings | |
| Certified Occupational Therapy Assistant (COTA)/Director of Rehabilitation (DOR) | Named in occupational therapy implementation finding | |
| Registered Nurse (RN) | Named in respiratory care and fall risk assessment findings | |
| Consultant Pharmacist (CP) | Named in medication management and expired drug removal findings | |
| Nurse Practitioner (NP) | Named in nutritional and medication documentation findings | |
| Infection Preventionist Nurse (IPN) | Named in vaccination and wound care findings |
Inspection Report
Annual Inspection
Census: 64
Capacity: 100
Deficiencies: 12
Date: Mar 27, 2024
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long-Term Care Facilities, including complaint investigations.
Complaint Details
Complaint numbers NJ 167761, NJ 170615, NJ 171733 were investigated during this survey.
Findings
Deficiencies were cited in multiple areas including comprehensive assessments, encoding/transmitting resident assessments, accuracy of assessments, professional standards of care, pressure ulcer prevention, range of motion, nutrition/hydration, respiratory care, pharmacy services, resident records, payroll based journal submission, influenza and pneumococcal immunizations, and multiple life safety code violations related to building construction, fire safety, sprinkler systems, fire alarm systems, portable fire extinguishers, HVAC ventilation, electrical systems, and door maintenance.
Deficiencies (12)
Failure to complete and submit electronically the Minimum Data Set (MDS) within 14 days of completion for multiple residents.
Failure to accurately code the Minimum Data Set (MDS) for multiple residents.
Failure to assess and provide care for a resident at risk for falls according to professional standards.
Failure to provide care to prevent pressure ulcers and to treat existing pressure ulcers according to professional standards.
Failure to implement restorative nursing interventions and revise care plans timely for residents using splints or assistive devices.
Failure to maintain acceptable nutritional and hydration status and to follow interdisciplinary recommendations for residents with significant weight loss.
Failure to provide respiratory care and physician orders consistent with professional standards for a resident with tracheostomy care needs.
Failure to submit Payroll Based Journal (PBJ) staffing data to CMS for Fiscal Year Quarter 1 2024.
Failure to offer pneumococcal immunization to a resident and document consent and administration properly.
Life Safety Code violations including building construction type exceeding allowed height for wood-frame structures, inadequate number of exits, vertical openings not enclosed with 1-hour fire rated construction, missing sprinkler coverage in stairwell landing, failure to maintain portable fire extinguishers, failure to conduct hydrostatic testing of kitchen range hood fire suppression system, failure to conduct smoke detector sensitivity testing, failure to maintain fire alarm system, failure to provide ventilation in resident bathrooms, and failure to provide GFCI protection for electrical outlets near water sources.
Failure to maintain electrical outlets near water sources with required Ground-Fault Circuit Interrupter (GFCI) protection.
Failure to maintain fire-rated doors with properly functioning latching systems.
Report Facts
Census: 64
Total Capacity: 100
Deficiencies cited: 26
Fire extinguisher maintenance interval: 6
Fire extinguisher maintenance interval: 1
Smoke detector sensitivity testing interval: 2
Hydrostatic testing interval: 12
GFCI outlet distance: 6
Resident rooms inspected: 45
Resident bathrooms inspected: 13
Electrical outlets tested: 9
Electrical outlets failed GFCI test: 5
Fire alarm systems inspected: 1
Fire alarm sensitivity testing missing: 1
Exit access doors tested: 9
Exit access doors failed latching test: 1
Inspection Report
Complaint Investigation
Census: 68
Capacity: 100
Deficiencies: 15
Date: Sep 15, 2023
Visit Reason
A complaint investigation and recertification survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Complaint Details
Complaint NJ #: 163930; 166007. The complaint involved multiple issues including environmental concerns, infection control, staffing, and medication management.
Findings
Deficiencies were cited related to environmental concerns including failure to maintain a safe, clean, comfortable, and homelike environment; failure to maintain and clean resident equipment properly; failure to complete and transmit resident assessments timely and accurately; failure to clarify medication orders; failure to post nurse staffing information daily; failure to properly label and store medications and biologicals; failure to maintain food safety standards; and failure to follow infection prevention and control practices including hand hygiene. Life Safety Code deficiencies were also cited related to building construction, exits, hazardous area enclosures, and fire door maintenance.
Deficiencies (15)
Facility failed to maintain resident living environment in a clean, comfortable, homelike manner with stained curtains, chipped molding, holes in walls, and improper bed placement.
Facility failed to clean and maintain resident equipment properly, including soiled respiratory equipment.
Facility failed to complete and transmit discharge Minimum Data Set (MDS) for a discharged resident.
Facility failed to accurately code a resident's MDS related to antipsychotic medication use.
Facility failed to clarify physician's order for medication dosage on electronic Medication Administration Record (eMAR).
Facility failed to post nurse staffing information daily and timely in a prominent location.
Facility failed to properly label, date, and store biologicals and discard medications after expiration.
Facility failed to properly handle and store potentially hazardous foods and maintain kitchen equipment and areas to prevent microbial growth and cross contamination.
Facility failed to follow appropriate infection control practices and hand hygiene during meal service.
Facility failed to maintain required minimum direct care staff to resident ratio as mandated by the State of New Jersey.
Facility failed to comply with building construction requirements for wood-frame structures exceeding allowed height.
Facility failed to provide two acceptable exits from each floor or fire section of the building.
Facility failed to ensure vertical openings between floors were enclosed with 1-hour fire-rated construction.
Facility failed to ensure fire-rated doors to hazardous areas were labeled in accordance with NFPA 101.
Facility failed to inspect all fire-rated door assemblies for proper operation as required by NFPA 101 and NFPA 80.
Report Facts
Census: 68
Total Capacity: 100
Deficiencies cited: 15
Staffing ratio: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Named in relation to findings on fire safety, door maintenance, and labeling of fire-rated doors | |
| Administrator in Training | Named in relation to fire safety code survey and building construction findings | |
| Licensed Nursing Home Administrator | Named in relation to staffing and medication order findings | |
| Director of Nursing | Named in relation to infection control, staffing, and medication order findings | |
| Housekeeping Director | Named in relation to environmental cleanliness and housekeeping practices | |
| Registered Nurse | Named in relation to resident equipment cleaning and infection control | |
| Licensed Practical Nurse/Infection Preventionist | Named in relation to infection control and resident equipment cleaning | |
| Recreation Aide | Named in relation to infection control and hand hygiene during meal service | |
| Staffing Coordinator | Named in relation to nurse staffing posting and staffing ratio compliance |
Inspection Report
Routine
Deficiencies: 8
Date: Sep 15, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory standards related to resident care environment, resident assessments, medication management, staffing, food safety, infection control, and other facility operations.
Findings
The facility was found deficient in maintaining a clean and homelike environment, accurate and timely resident assessments, proper medication order clarification, daily posting of nurse staffing reports, appropriate medication storage and labeling, safe food handling and storage, and infection prevention practices including hand hygiene during meal distribution.
Deficiencies (8)
Failure to maintain the resident's living environment in a clean, comfortable, homelike manner with stained curtains, damaged walls, and unclean equipment.
Failure to complete and transmit discharge Minimum Data Set (MDS) for a discharged resident.
Failure to accurately code a resident's Minimum Data Set (MDS) related to antipsychotic medication use.
Failure to clarify a Physician's Order for medication dosage on the electronic Medication Administration Record for several months.
Failure to post the Nursing Home Resident Care Staffing Report daily.
Failure to appropriately label, date, and store biologicals and discard medications after manufacturer specified use-by date.
Failure to properly handle and store potentially hazardous foods and maintain kitchen equipment to prevent microbial growth and cross contamination.
Failure to perform hand hygiene between residents during meal distribution, increasing risk of infection spread.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Medication administration times: 4
Medication dose: 15
Medication storage discard timeframe: 30
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Housekeeping Director | Housekeeping Director | Interviewed about cleaning schedules and privacy curtain replacement |
| Maintenance Director | Maintenance Director | Interviewed about maintenance and painting schedules |
| Licensed Nursing Home Administrator | Licensed Nursing Home Administrator | Interviewed about renovations, staffing, and policies |
| Registered Nurse | Registered Nurse | Caring for Resident #63 and acknowledged cleaning responsibilities |
| Housekeeper | Housekeeper | Responsible for cleaning resident rooms and equipment |
| Licensed Practical Nurse/Infection Preventionist | Licensed Practical Nurse/Infection Preventionist | Interviewed about cleaning responsibilities and infection control |
| Minimum Data Set Coordinator | Minimum Data Set Coordinator | Interviewed about MDS submission and coding |
| Certified Nursing Aide | Certified Nursing Aide | Interviewed about resident behavior and care |
| Licensed Practical Nurse | Licensed Practical Nurse | Observed medication preparation and interviewed about medication orders |
| Medical Director | Medical Director | Interviewed about medication order clarification |
| Staffing Coordinator | Staffing Coordinator | Interviewed about posting of staffing reports |
| Receptionist | Receptionist | Interviewed about posting of staffing reports |
| Food Services Director | Food Services Director | Interviewed about food storage and kitchen cleanliness |
| Consultant Pharmacist | Consultant Pharmacist | Interviewed about medication storage and labeling |
| Recreation Aide | Recreation Aide | Observed during meal tray pass and interviewed about hand hygiene |
Inspection Report
Abbreviated Survey
Census: 62
Deficiencies: 0
Date: Jun 14, 2023
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations.
Findings
The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Sample Size: 5
Inspection Report
Deficiencies: 0
Date: Jun 14, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction for Cranford Park Care, documenting the results of a regulatory survey completed on June 14, 2023.
Findings
No health deficiencies were found during the survey.
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Apr 19, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide physician-ordered antidiabetic and antibiotic medications in a timely manner for two residents.
Complaint Details
The complaint investigation found that Resident 1 did not receive ordered Trulicity on multiple dates between 11/16/22 and 12/14/22, with no documentation of notification to the Nurse Practitioner or Medical Director. Resident 8 did not receive the first dose of Keflex antibiotic until approximately 13 hours after the pharmacy received the order and over 15 hours after returning to the facility. Interviews confirmed failures in timely medication administration and communication.
Findings
The facility failed to timely obtain and administer ordered medications for two residents, resulting in potential harm from uncontrolled blood sugar and untreated infection. Documentation and communication failures were noted regarding medication availability and notification of responsible staff.
Deficiencies (2)
Failure to obtain and administer physician-ordered antidiabetic medication (Trulicity) timely for Resident 1.
Failure to administer antibiotic (Keflex) timely for Resident 8 after hospital return.
Report Facts
Delay in antibiotic administration: 13
Delay in antibiotic administration: 15
Medication non-administration dates: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 1 | Licensed Practical Nurse | Interviewed regarding medication administration procedures and confirmed lack of documentation for Resident 1 |
| Licensed Practical Nurse 3 | Licensed Practical Nurse | Interviewed and confirmed notification to Nurse Practitioner 1 but no documentation for missed Trulicity doses for Resident 1 |
| Director of Nursing | Director of Nursing | Reviewed clinical records and confirmed medication administration failures and lack of notification |
| Medical Director | Medical Director | Interviewed regarding expectations for medication availability and notification |
| Nurse Practitioner 1 | Nurse Practitioner | Notified by Licensed Practical Nurse 3 about missed Trulicity doses but documentation was lacking |
| Infectious Diseases physician | Infectious Diseases physician | Stated that Resident 8 should have received antibiotic within six hours of return to facility |
Inspection Report
Complaint Investigation
Census: 69
Deficiencies: 1
Date: Apr 19, 2023
Visit Reason
A complaint survey was conducted on behalf of the New Jersey Department of Health due to complaints NJ00161489 and NJ00162174.
Complaint Details
Complaint survey based on complaints NJ00161489 and NJ00162174. The facility was found not in substantial compliance with 42 CFR Part 483, Subpart B, for long term care facilities.
Findings
The facility failed to obtain physician-ordered medications in a timely manner for two residents, R1 and R8, which posed potential harm. Documentation was lacking regarding medication administration and notifications to medical staff. The facility did not follow proper procedures for medication availability and notification.
Deficiencies (1)
Failed to obtain physician ordered medications in a timely manner for two residents, resulting in potential harm.
Report Facts
Survey Census: 69
Sample Size: 9
Correction Completion Date: Apr 25, 2023
Post-Certification Revisit Date: May 16, 2023
Time delay for medication administration: 15
Time delay for medication administration: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN1 | Licensed Practical Nurse | Interviewed regarding medication administration procedures and delays |
| LPN3 | Licensed Practical Nurse | Interviewed regarding notification of medication issues for resident R1 |
| Director of Nursing | Director of Nursing (DON) | Reviewed records, confirmed deficiencies, and described expectations for medication administration and notification |
| Medical Director | Medical Director | Provided expectations for medication availability and timely administration |
| Infectious Diseases Physician | Facility Infectious Diseases Physician | Stated R8 should have received medication within six hours of return due to pharmacological properties |
Inspection Report
Complaint Investigation
Census: 67
Deficiencies: 0
Date: Dec 6, 2022
Visit Reason
The inspection was conducted as a complaint investigation based on complaint #NJ158481.
Complaint Details
Complaint #NJ158481; the facility was found in substantial compliance.
Findings
The facility was found to be in substantial compliance with the requirements of 42 CFR Part 483, Subpart B, for long term care facilities based on this complaint visit.
Report Facts
Sample size: 3
Inspection Report
Follow-Up
Deficiencies: 4
Date: Jun 16, 2022
Visit Reason
The inspection was conducted to assess compliance with New Jersey Administrative Code standards for licensure of Long Term Care Facilities, focusing on staffing ratios, infection control, employee health screenings, and emergency preparedness.
Findings
The facility was found deficient in maintaining minimum direct care staff-to-resident ratios, ensuring timely physical examinations and two-step Mantoux tuberculosis testing for new employees, and properly inviting emergency management officials to evacuation drills. Corrective actions and plans of correction were documented for each deficiency.
Deficiencies (4)
Failed to maintain required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey.
Failed to ensure new employees received physical examinations within required time frames.
Failed to ensure employees had two-step Mantoux tuberculosis skin testing completed upon hire.
Failed to invite Local, County, and State emergency management officials to emergency drills at least 10 working days in advance.
Report Facts
Deficient CNA staffing day shifts: 5
Residents on day shifts requiring CNAs: 9
Employee files reviewed: 5
Employees without timely physicals: 2
Employees without two-step Mantoux testing: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Employee #3 | Did not have physical examination completed upon hire; physical done previously at another facility. | |
| Employee #5 | Did not have physical examination completed upon hire; physical done previously at another facility. | |
| Employee #1 | Had only one-step Mantoux tuberculosis skin test upon hire; second step missing. | |
| Employee #2 | Had only one-step Mantoux tuberculosis skin test upon hire; second step missing. | |
| Employee #4 | Had only one-step Mantoux tuberculosis skin test upon hire; second step missing. |
Inspection Report
Life Safety
Census: 69
Capacity: 100
Deficiencies: 16
Date: Jun 16, 2022
Visit Reason
The facility underwent a Life Safety Code Survey conducted by the New Jersey Department of Health on 6/13/22 and 6/14/22 to assess compliance with Medicare/Medicaid participation requirements and the 2012 Edition of the National Fire Protection Association (NFPA) 101 Life Safety Code.
Findings
The facility was found to be noncompliant with multiple Life Safety Code requirements including emergency preparedness plan review, building construction type, means of egress, fire door inspections, egress door locking mechanisms, number of exits, discharge from exits, illumination of means of egress, vertical openings enclosure, hazardous area door closures, fire alarm system testing and maintenance, sprinkler system installation and maintenance, corridor door smoke resistance, elevator inspections, electrical system reliability, and gas cylinder storage.
Deficiencies (16)
Failed to fully review and sign the Emergency Preparedness Plan annually.
Annex section building exceeded the 1-story height requirement for wood-frame structures.
Failed to inspect fire doors annually; no documentation for last 12 months.
Exit doors in means of egress were obstructed or locked improperly, including hook-type deadbolt and non-functioning delayed egress features.
Failed to provide two acceptable exits from each floor or fire section; stairways were winding and second exit was through a dining room leading to a fire escape.
Exit discharge landing was uneven, creating a tripping hazard.
Corridor lighting could be shut off manually, disabling emergency illumination unless power was lost.
Vertical openings between floors were not enclosed with 1-hour fire-rated construction.
Failed to provide self-closing devices on doors to hazardous areas.
Fire alarm system inspections were not conducted semiannually; smoke detectors over 10 years old; manual pull stations failed to report to panel.
Fire sprinkler system did not provide coverage to a closet outside the conference room.
Sprinkler system ceiling penetrations were not properly sealed; missing sprinkler head finish cap and open ceiling around pipes and wiring.
Corridor doors failed to resist passage of smoke due to improper latching, holes, or obstructions preventing closure.
Elevator annual inspection was overdue by almost 4 months.
Failed to certify generator transfer time within 10 seconds and lacked a remote manual stop station.
Portable oxygen cylinders were not secured properly in storage, posing tipping and damage risks.
Report Facts
Certified beds: 100
Census: 69
Fire doors not inspected: 9
Delayed egress doors with issues: 2
Corridor doors with deficiencies: 4
Elevator devices: 2
Portable oxygen cylinders unsecured: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Present during interviews and informed of findings at exit conferences. | |
| Regional Operations Director | Present during interviews and informed of findings at exit conferences. | |
| Maintenance Director | Interviewed regarding deficiencies, responsible for corrective actions and audits. |
Inspection Report
Routine
Deficiencies: 16
Date: Jun 16, 2022
Visit Reason
The inspection was a routine recertification survey to assess compliance with regulatory requirements including resident care, infection control, medication management, and facility safety.
Findings
The facility was found deficient in multiple areas including failure to preserve resident dignity, incomplete care plans, medication administration errors, unsafe water temperatures, improper infection control practices, incomplete physician order signatures, missing consultant pharmacist visits, expired medications, inaccurate staffing postings, and inadequate resident room space.
Deficiencies (16)
Failure to preserve resident dignity related to urinary drainage bag placement visible from hallway.
Failure to follow wound treatment protocols including improper hand hygiene and not following physician's order for dressing.
Failure to develop and implement comprehensive, person-centered care plans for multiple residents including hospice, oxygen use, pain management, and dialysis care.
Failure to ensure medications were safely secured, accurately documented, and administered according to physician orders.
Failure to maintain water temperatures at safe levels, resulting in immediate jeopardy to resident health and safety.
Failure to provide safe and appropriate respiratory care by not administering oxygen as ordered.
Failure to provide safe and appropriate dialysis care including incomplete communication and post-dialysis assessments.
Failure to ensure physician signed and dated monthly physician orders for multiple residents.
Failure to post nurse staffing information daily in a visible area for residents and visitors.
Failure to ensure monthly consultant pharmacist medication regimen review and unit inspection for May 2022.
Failure to properly remove expired medications and medications with shortened expiration dates from medication carts and storage areas.
Failure to procure, store, prepare, and serve food in accordance with professional standards including storage of raw eggs above cooked food and unclean ice machine.
Failure to safeguard resident-identifiable information and maintain consistent medical records related to code status and allergies.
Failure to provide and implement an infection prevention and control program including improper use of PPE, improper hand hygiene, and improper storage of urinary drainage bags.
Failure to ensure staff were vaccinated and boosted for COVID-19 as required by facility policy.
Failure to provide rooms with at least 80 square feet per resident in multi-bedded rooms.
Report Facts
Staff vaccination compliance: 42.7
Staff total: 89
Staff boosted: 35
Water temperature: 146.5
Water temperature: 124.5
Water temperature: 134.9
Water temperature: 139.4
Water temperature: 138.8
Water temperature: 112.4
Water temperature: 123.4
Water temperature: 127.4
Water temperature: 122.2
Water temperature: 120.8
Expired medication count: 6
Room size: 140
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in medication administration and dialysis care findings |
| LPN #3 | Licensed Practical Nurse | Named in infection control PPE findings |
| CNA #3 | Certified Nursing Assistant | Named in infection control PPE findings |
| CNA #4 | Certified Nursing Assistant | Named in infection control PPE findings |
| CNA #5 | Certified Nursing Assistant | Named in infection control PPE findings |
| LPN #5 | Licensed Practical Nurse | Named in infection control PPE findings |
| CNA #8 | Certified Nursing Assistant | Named in infection control PPE findings |
| CNA #9 | Certified Nursing Assistant | Named in infection control PPE findings |
| LPN #6 | Licensed Practical Nurse | Named in wound treatment hand hygiene findings |
| RN | Registered Nurse | Named in dignity and oxygen care findings |
| Director of Nursing | Director of Nursing | Named in multiple findings discussions |
| Administrator | Administrator | Named in multiple findings discussions |
| Regional Consultant Pharmacist | Consultant Pharmacist | Named in medication regimen review findings |
| Housekeeping Director | Housekeeping Director | Named in PPE and infection control findings |
| Food Service Director | Food Service Director | Named in food safety and hand hygiene findings |
Inspection Report
Complaint Investigation
Census: 60
Deficiencies: 2
Date: Nov 15, 2021
Visit Reason
The inspection was conducted as a complaint survey based on Complaint Intake #NJ143545 and NJ145559, triggered by allegations related to quality of care and staffing ratios at the facility.
Complaint Details
Complaint Intake #NJ143545 and NJ145559. The complaint investigation found substantiated deficiencies related to quality of care and staffing shortages.
Findings
The facility was found not in compliance with quality of care standards due to improper application of briefs for one resident and failure to meet minimum staffing ratios for three of 14 shifts reviewed. The deficient practices had the potential to affect all residents.
Deficiencies (2)
Facility failed to properly apply briefs for one resident, resulting in improper care.
Facility failed to ensure staffing ratios were met for three of 14 shifts reviewed.
Report Facts
Census: 60
Sample Size: 8
Staffing Deficiencies: 3
Staff to Resident Ratios: 6
Staff to Resident Ratios: 7
Staff to Resident Ratios: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Interviewed regarding improper briefing of resident and staff re-education |
| Administrator | Administrator | Interviewed regarding briefing practices and staffing issues |
| CNA #2 | Certified Nurse Aide | Re-educated and suspended for improper use of briefs on resident |
| CNA #3 | Certified Nurse Aide | Observed providing care and interviewed about briefing practices |
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