Cranbury Center

In the surveyor’s words

From the most serious findings on record at Cranbury Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF604May 28, 2026

  Based on observation, interviews, review of medical records, and review of other pertinent facility documents on 05/28/2026, it was determined that the facility failed to maintain an environment free from the use of physical restraint for Resident #2.This deficient practice was identified for 1 of 6 residents (Resident #2) reviewed for restraint.During the survey, a tour was conducted by the surveyor, there was no restrictive device noted for any resident.On 05/23/2026, during the 7:00 AM-3:00 PM shift, the Registered Nurse (RN#1) who was assigned to Resident #2 stated the resident was experiencing respiratory distress. RN#1 administered a respiratory treatment by nebulizer mask. RN#1 stated during the treatment Resident #2 became combative and pulled off the mask from their face. […]

• Immediate jeopardy, isolatedF578Dec 4, 2025

  Based on interview and review of pertinent facility documents, it was determined that the facility failed to ensure the code status for a resident (Resident # 61) was accurately documented in the electronic medical record (EMR) that correctly identified their wishes in the event of a medical emergency. This deficient practice was identified for 1 out of 37 residents (Resident # 61). Resident # 61 wished to be a Do Not Resuscitate (DNR; do not perform cardiopulmonary resuscitation (CPR) if a person's heart stops or they cease breathing). A review of the resident's EMR revealed that Resident # 61's code status was documented as DNR/Full Code (all resuscitation procedures will be provided when a person stops breathing or their heart stops beating). […]

• Immediate jeopardy, isolatedF689Sep 29, 2022

  C#: NJ158046 Based on interviews, medical records reviews, and review of other pertinent facility documentation on 9/21/2022, 9/26/2022, and 9/29/2022, it was determined that the facility failed to supervise and monitor a moderately cognitively impaired resident (Resident #2) appropriately, with a known diagnosis of Anoxic Brain Damage, Cognitive Communication Deficit, Unspecified Dementia with Behavioral Disturbance, Generalized Muscle Weakness, and Unspecified Altered Mental Status, from eloping on 8/20/2022. Resident #2 eloped from the facility, unknowing to the facility staff. […]

• No harm, potential for more than minimal, widespreadF812Dec 4, 2025

  Based on observation, interviews, and facility policy review, the facility failed to ensure areas in the kitchen remained sanitary including sanitation buckets remaining at the correct Parts Per Million (PPM) level, the outside of the ice machine was cleaned, dry storage was properly labeled and dated, broken equipment was not used and covers for the steam table were clean when in use. This failure had the potential to affect the spread of food borne illness for 100 of 101 total sampled residents. Findings include:During the initial kitchen tour on 12/01/25 at 10:30 AM with the Dietary Manager (DM), the following observations were made: 1. The sanitary bucket used for wiping cloths, located on the shelf near the floor, was tested and revealed 0 PPM of sanitizer. 2. […]

• No harm, potential for more than minimal, patternF641Dec 4, 2025

  Based on record review and interview, the facility failed to ensure that four residents (R70, R11, R77, and R20) out of 37 residents sampled had a Minimum Data Set (MDS) that accurately reflected their Preadmission Screening and Resident Review (PASRR) Level II status. This had the potential to affect all residents who qualified for a PASRR Level II. Findings include:1.Review of R70's admission Record located in the Profile tab of the electronic medical record (EMR) revealed a re-admission to the facility on [DATE]. Review of R70's annual MDS under the MDS tab of the EMR, with an Assessment Reference Date (ARD) of 06/29/25, revealed no indication of a Mental Illness or Level II services. […]