The Elms Rehab and Healthcare Center of Cranbury

In the surveyor’s words

From the most serious findings on record at The Elms Rehab and Healthcare Center of Cranbury, in the surveyor’s own words.

• Immediate jeopardy, isolatedF604Feb 12, 2026

  Complaint #: 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. […]

• Immediate jeopardy, isolatedF689Dec 20, 2024

  Complaint #: 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. […]

• Immediate jeopardy, isolatedF835Dec 20, 2024

  Complaint #: 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. […]

• No harm, potential for more than minimal, patternF759Sep 25, 2022

  Complaint Intake #NJ154751 Based on observation, interviews, record review, and facility policy review, it was determined the facility failed to maintain a medication error rate below 5% for 1 (Resident #8) of 4 residents observed during medication passes conducted by three licensed nurses. The medication error rate was 8%, based on a total of 25 opportunities observed and a total of two medication errors detected. Findings included: Review of an Order Summary Report, revealed Resident #8 had a physician's order dated 09/16/2022 for a multivitamin with minerals one tablet daily for supplement. Additionally, the resident had a physician's order dated 09/22/2022 for cyanocobalamin (Vitamin B12) 1000 mcg, one tablet daily for B12 deficiency. […]

• No harm, potential for more than minimal, patternF695Nov 19, 2021

  Based 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. A review of Resident #11's Admission Record indicated Resident #11 was admitted with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]