The Elms Rehab and Healthcare Center of Cranbury

Inspectors wroteComplaint #: 2720895Based on interviews and review of pertinent facility documents on 1/27/26 and 1/29/26, it was determined that the facility failed to ensure that a resident (Resident #1) who had severely impaired cognition, behaviors, and underlying medical infection was free from physical restraints imposed for purposes of care convenience and not required to treat the resident's medical symptoms. On 01/16/26, around 6:30 PM, Resident #1's family member walked into the resident's room and found the resident alone in their room. The resident was seated in a wheelchair with dinner on the overbed tray table in front of them, and a white bed sheet wrapped around their waist and tied behind the resident's wheelchair. This deficient practice occurred for 1 of 4 sampled residents (Resident #1). [...]

Inspectors wroteComplaint # 432327Based on observation, interview, record review and review of pertinent facility documents, it was determined that the facility failed to ensure that incontinence and hygiene care was provided to residents who were dependent on staff for activities of daily living (ADL) care. The deficient practice occurred for 1 of 2 residents (Resident #100) reviewed for ADL's and was evidenced by the following: Complaint #On 9/23/25 at 10:30 AM, the surveyor interviewed the Lead Certified Nurse Aide (CNA) regarding where the care provided was documented. The CNA informed the surveyor that all CNAs where to document the care provided on the Electronic Medical Record. The CNA was able to show to the surveyor where the care provided was documented. The CNA informed the surveyor that licensed staff had access and could print the document if needed. [...]

Inspectors wroteBased on interview, review of the medical record and other facility documentation, it was determined that the facility failed to maintain Hospice Communication Records for 1 of 2 residents (Resident #95) reviewed for Hospice Services. This deficient practice was evidenced by the following:failed to ensure all residents medical record were readily accessible and available for review by the survey team. This deficient practice was identified for Resident #95, 1 of 2 residents reviewed for Hospice Services and was evidenced by the following: On 9/19/25 at 10:21 AM, the surveyor reviewed Resident #95's electronic medical record. The admission Face sheet, an admission summary reflected that Resident #95 was admitted to the facility with diagnoses which included but were not limited to; [...]

Inspectors wroteComplaint #: NJ00181255, NJ00181471 Based on observations, interviews, medical record review, and review of other pertinent facility documents on 12/17/2024, it was determined that the facility failed to ensure resident safety by using portable space heaters in resident rooms when the boilers became non-operational. The Maintenance Director (MD) stated he received a call on 12/8/24 from a staff member that a resident was complaining about the temperature being cold in their room. The MD stated he went to the facility and noticed that the boilers were not operational and supplemental heat was needed in certain areas of the facility. The MD notified the Licensed Nursing Home Administrator (LNHA) that the boilers were not operational and supplemental heat was required. The MD purchased the portable space heaters and placed them in the resident's rooms. [...]

Inspectors wroteComplaint #: NJ00181255, NJ00181471 Based on observations, interviews, medical record review, and review of other pertinent facility documents on 12/17/2024, it was determined that the Licensed Nursing Home Administrator (LNHA) failed to ensure the resident safety by allowing the use of space heaters in resident rooms while the boilers were not operational. The Maintenance Director (MD) notified the LNHA that the boilers were not operational and supplemental heat was required. The MD purchased the portable space heaters and placed them in the resident's rooms. The two non-operational boilers were replaced on 12/10/24. The facility discontinued using the portable space heaters on 12/11/2024. There were 38 cognitively impaired residents in the facility on 12/8/24 and there were 10 residents prescribed oxygen on 12/8/24. [...]

Inspectors wroteComplaint NJ #161104 Based on record review, interviews and other facility documentation, it was determined that the facility failed to notify the Board of Nursing (BON) (evaluates license applications, issues licenses, renews licenses, and takes disciplinary action in response to professional misconduct) for a Licensed Practical Nurse/Supervisor (LPN/S #1) who was under investigation for misappropriation of Residents' narcotic medication. This deficient practice was identified for one of one investigation reviewed. This deficient practice was evidenced by the following: On 02/21/24 at 2:40 pm, the Director of Nursing (DON #1) provided the survey team with a file for an investigation dated 12/18/22. A review of the file revealed a Reportable event [Resident's name redacted] 12/18/22; Summary and Conclusion: [...]

Inspectors wroteBased on observation, interview, record review and review of pertinent facility documents, it was determined that the facility failed to ensure the medication error rates were not 5% or greater. During the morning medication administration observation on 2/20/24, the surveyor observed two (2) nurses administer medications to four (4) residents. There were 37 opportunities, and two (2) errors were observed which calculated to a medication administration error rate of 5.41%. This deficient practice was identified for one (1) of four (4) residents, Resident# 83, that was administered medications by one (1) of the two (2) nurses that were observed. The deficient practice was evidenced by the following: [...]

Inspectors wroteBased on observation, interview, record review and review of pertinent facility documents it was determined that the facility failed to complete and submit a Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, in accordance with the federal guidelines of the MDS 3.0 Resident Assessment Instrument (RAI) for 1(Resident #33) of 1 resident reviewed for hospitalizations. This deficient practice was evidenced by the following: On 02/14/24 at 11:30 AM, the surveyor observed Resident #33 in his/her room lying in bed. Resident #33 was alert and verbally responsive, the resident was observed wearing oxygen via nasal cannula (a medical device which provides supplemental oxygen therapy). The surveyor interviewed Resident #33, in reference to his/her hospitalizations. [...]

Inspectors wroteBased on observations, interview, record review and review of the pertinent facility documentation it was determined the facility failed to: a.) ensure that oxygen tubing was appropriately labeled and dated, b.) the nasal canula was stored in a way to prevent bacterial microbial growth, c.) the oxygen humidification bottle was checked to ensure the appropriate water level for humidification, and d.) the facility followed their Policy and Procedure for Oxygen Administration. This deficient practice was identified for three of four residents, (Resident #11, Resident #27, and Resident #50) reviewed for respiratory care and was evidenced by the following. 1. [...]

Inspectors wroteBased on observation, interview, review of medical records and review of facility documentation, it was determined the facility failed to document on the Care Plan (CP) a residents use and refusal of a hearing aid. This deficient practice was identified for 1 of 25 residents, (Resident #25) reviewed for CP. On 11/15/21 at 9:16 AM, the surveyor observed Resident #25 lying in bed, eyes closed. The resident did not respond to the surveyors greeting. On 11/16/21 at 9:59 AM, the surveyor observed the Certified Nursing Aide (CNA) enter the resident's room. The CNA spoke loudly to the resident. On 11/16/21 at 12:38 PM, the surveyor observed Resident #25 in their room sitting in a wheelchair. The surveyor did not observe any hearing aids in either of the resident's ears. On 11/17/21 at 11:55 AM, the surveyor observed the resident in bed and did not observe any hearing aids in either ear. [...]

Inspectors wroteBased on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility staff failed to: a) consistently follow a physician order for the application of a hip protector (device to minimize risk of injury in the presence of fall), b.) ensure that a resident's hearing aid used to facilitate communication was applied as ordered by the physician, and c.) accurately following a Physician's Order (PO) to hold a medication (Clonidine) according to blood pressure results. This deficient practice was identified for three of 25 resident's, (Resident #27, #50, and #93) reviewed for professional standards of nursing practice. The deficient practice was evidenced by the following: Reference: New Jersey Statutes Annotated, Title 45. Chapter 11. Nursing Board. The Nurse Practice Act for the State of New Jersey states: [...]