Above average — CMS composite of the measures below.
The next survey window likely opens around October 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 The Elms Rehab And Healthcare Center Of Cranbury during CMS and state inspections, most recent first.
A resident with dementia, severely impaired cognition (BIMS 0), behavioral issues including disrobing, and C-diff on contact precautions was served dinner in a wheelchair by a CNA who placed a sheet over the resident’s lap to prevent tampering with briefs or pants. When the sheet repeatedly fell, the CNA loosely tied it around the resident’s waist and behind the wheelchair, creating a physical restraint that restricted the resident’s movement and access to their body. The resident’s family later entered the room, found the resident alone with the dinner tray in place and the sheet wrapped and tied around the waist and wheelchair, and alerted staff. The nursing supervisor confirmed the sheet was tied around the resident and wheelchair, with no staff present, and removed it. This restraint use was contrary to facility policy, which allowed restraints only to treat medical symptoms and not for staff convenience, and resulted in an Immediate Jeopardy finding.
Failure to document and verify ADL incontinence and hygiene care: A resident with dementia, COPD, muscle weakness, and total dependence for bathing and incontinence care had missing EMR entries for incontinence care, bowel management, personal hygiene, and shower/bath care across multiple shifts. The care plan ordered assistance with bathing and hygiene and twice-weekly bath/shower care, but the record showed no documentation of provision or refusal, and the DON confirmed the care could not be verified as having been provided.
A resident admitted for hospice care with advanced cancer and severe cognitive impairment had hospice-related orders and a note showing hospice nurse recommendations, but the facility could not produce the hospice communication log or other hospice records for survey review. The LPN/UM and DON both acknowledged the records were unavailable, and the DON also confirmed there was no documentation of an interdisciplinary meeting to discuss hospice services.
The facility used portable space heaters in resident rooms when the boilers failed, posing a fire hazard, especially for residents on oxygen therapy. The Maintenance Director and LNHA were aware of the regulations against using space heaters but proceeded due to the emergent situation. Residents reported the presence of heaters in their rooms, including those with cognitive impairments and on oxygen therapy.
The LNHA allowed the use of portable space heaters in resident rooms when the facility's boilers were non-operational, despite knowing the fire hazard risks. This decision affected 38 cognitively impaired residents and 10 residents on oxygen, creating an Immediate Jeopardy situation. The LNHA justified the action as necessary for resident comfort during the emergent situation.
The facility failed to notify the BON about an LPN under investigation for misappropriation of residents' narcotic medication. Despite notifying the police and DEA, the facility did not report the incident to the BON as required. The LPN did not attend a scheduled meeting to discuss the investigation and was considered to have voluntarily resigned. The administrative team later acknowledged the oversight and submitted a report to the BON.
The facility failed to maintain a medication error rate below 5%. An LPN administered medications to a resident without ensuring the resident had eaten, despite the medications' requirements to be taken with food. This resulted in a medication administration error rate of 5.41%.
The facility failed to complete and submit a Minimum Data Set (MDS) for a resident in accordance with federal guidelines. The resident, who had chronic systolic heart failure, acute and chronic respiratory failure with hypoxia, and chronic kidney disease stage 3, had multiple hospitalizations, but the MDS tracking records for one hospitalization were not completed within the required timeframe. The MDS Coordinator acknowledged the oversight.
Improper Use of Sheet as Physical Restraint During Mealtime
Penalty
Summary
The deficiency involves the use of a physical restraint on a resident with severely impaired cognition, behaviors, and an underlying C-diff infection, in a manner that was for staff convenience and not required to treat a medical symptom. The facility’s own restraint policy stated that restraints were to be used only for the safety and well-being of residents, only after other alternatives had been tried unsuccessfully, and never for discipline, staff convenience, or fall prevention. Physical restraints were defined in the policy as any manual method or device attached or adjacent to the resident’s body that the individual cannot remove easily and that restricts freedom of movement or normal access to one’s body. The resident had dementia, dysphagia, anxiety disorders, and osteoporosis, and an MDS assessment showed a BIMS score of 0/15, indicating severely impaired cognition. The care plan documented impaired cognitive function related to dementia and behavior issues including grabbing, pushing, putting small objects in the mouth, removing briefs and leaving them anywhere, and removing an ace bandage from the left lower extremity. The resident was also on antibiotics and had C-diff, with care plan interventions including contact isolation, use of gowns and masks when changing contaminated linens, disinfection of equipment, and education of resident, family, and staff regarding infection prevention. Additional care plan entries indicated the resident required contact precautions related to C-diff, including disposal of soiled products per policy, placement in a private room, assistance with position changes, and appropriate handwashing. On the evening of the incident, a CNA reported having been told that the resident was on isolation precautions for C-diff and had behaviors of taking off clothes and briefs. Around dinner time, the CNA served the resident’s meal and placed a sheet on the resident’s lap to prevent the resident from tampering with their brief or removing their pants during mealtime. The CNA stated that the sheet repeatedly fell to the floor and, due to concern that the resident, who ambulated impulsively, could trip or fall on the sheet, the CNA loosely tied the sheet around the resident’s waist and behind the wheelchair. Later that evening, the resident’s family member entered the room, found the resident alone in a wheelchair with the dinner tray in front, and discovered a white bed sheet wrapped around the resident’s waist and tied behind the wheelchair. When notified, the nursing supervisor observed the resident sitting upright in the wheelchair with the sheet over the lap and loosely secured behind the back, with no staff present in the room, and then removed the sheet. This use of a tied sheet around the resident’s waist and wheelchair constituted a physical restraint imposed for care convenience and not required to treat the resident’s medical symptoms, leading to an Immediate Jeopardy determination beginning at the time the sheet was applied during dinner.
Removal Plan
- Certified Nursing Assistant (CNA) #1 was immediately removed from resident care and suspended pending investigation.
- Nursing staff conducted an immediate comprehensive head-to-toe physical, skin, and neurological assessment, with no injuries identified.
- The resident's primary medical provider was notified.
- Responsible parties present in facility were notified.
- The NJDOH and Office of the Ombudsman were notified.
- Ongoing monitoring orders were initiated for three (3) consecutive days.
- All residents with a Brief Interview for Mental Status (BIMS) score of 11 or less received precautionary skin checks.
- All residents with BIMS score of 12 or higher were interviewed and denied witnessing or experiencing any abuse or concerning behavior related to CNA #1's assignment.
- Written statements were obtained from all staff involved.
- A full-house in-service training was initiated for all staff with emphasis on CMS F604 (Freedom from Abuse, Neglect, and Exploitation).
- Education reinforced that no improvised devices, linens, or methods may be used in any manner that could be perceived as restrictive, regardless of intent.
- Staff were re-educated on the requirement that only approved, care planned, and policy compliant interventions may be utilized at all times.
Failure to Document and Verify ADL Incontinence and Hygiene Care
Penalty
Summary
The facility failed to ensure that incontinence care, hygiene care, and shower or bath care were provided and documented for a resident who was dependent on staff for ADL care. Resident #100 was admitted with diagnoses including unspecified dementia, COPD, and muscle weakness, and the admission MDS showed the resident was moderately cognitively impaired, scored 12 out of 15 on the BIMS, and was totally dependent on staff for bathing and incontinence care. The care plan and orders directed staff to provide one-person assistance for bathing and hygiene, two-person assistance for mobility and transfer, and bath or shower care twice weekly with documentation of any refusals. During record review, the surveyor found that on multiple shifts care was not signed as provided and there was no documentation that the resident refused care on 2/16, 2/17, and 2/21/25. The facility’s documentation report showed missing entries for incontinence care, bowel management, personal hygiene, and shower or bath care across several shifts on those dates. The nurse’s progress notes did not provide a rationale for why the care was not entered in the clinical record, and the DON confirmed that the care was not entered and could not be verified as having been provided.
Missing Hospice Communication Records and Unavailable Medical Documentation
Penalty
Summary
The facility failed to maintain Hospice Communication Records for 1 of 2 residents reviewed for hospice services, and the resident’s medical record was not readily accessible for surveyor review. Resident #95 was admitted with diagnoses including lung cancer, brain cancer, and bone cancer, and the nursing admission evaluation documented that the resident was unable to participate in the admission process, was severely cognitively impaired, and was admitted for palliative care under hospice services. The individualized care plan included hospice-focused interventions such as hospice nurse visits, notification of hospice with any change in condition, and comfort measures. The record review showed an order for Do Not Hospitalize hospice code status and a progress note stating that a hospice nurse evaluated the resident and recommended returning Morphine to 0.5 mg every hour as needed and changing the code status to DNH per the resident representative’s request. When the surveyor asked for the hospice recommendations, the LPN/UM could not provide them and stated she was unsure where the communication log was, adding that the resident had been discharged and the facility could not locate the log. The DON acknowledged there was no documentation of an interdisciplinary meeting to discuss hospice services and that staff were unable to locate additional hospice records on site, confirming she did not have the hospice records available for review.
Use of Portable Space Heaters in Resident Rooms
Penalty
Summary
The facility failed to ensure resident safety by using portable space heaters in resident rooms when the boilers became non-operational. On 12/8/2024, the Maintenance Director (MD) was informed by a staff member that a resident complained about the cold temperature in their room. Upon inspection, the MD discovered that the boilers were not operational, necessitating supplemental heat in certain areas of the facility. The MD informed the Licensed Nursing Home Administrator (LNHA) about the situation, and portable space heaters were purchased and placed in residents' rooms, including those of cognitively impaired residents and residents on oxygen, despite the known fire hazard. The deficiency was identified during a survey on 12/17/2024, where it was noted that the use of portable space heaters in rooms with residents on oxygen posed a significant fire risk. Resident #6, who had pulmonary fibrosis and chronic respiratory failure, was on continuous oxygen therapy and had a portable space heater in their room. Similarly, Resident #5, with chronic obstructive pulmonary disease and on oxygen therapy, reported a plug-in heater being left in their room despite their request for its removal. Resident #4, with intact cognition, confirmed the lack of heat and the use of a portable heater in their room. The LNHA and MD were aware of the regulations against using portable space heaters due to fire concerns but deemed it necessary to maintain resident comfort during the emergent situation. The facility's Emergency Preparedness Plan for Fire Prevention required reporting and correcting hazardous conditions, but the use of space heaters was not aligned with these protocols. The Immediate Jeopardy situation was identified due to the risk posed to all residents, particularly those on oxygen therapy.
Removal Plan
- Education for the LNHA and MD on not using space heaters in the facility
- Education for all staff on not using the space heaters in the facility
Use of Space Heaters in Resident Rooms During Boiler Failure
Penalty
Summary
The Licensed Nursing Home Administrator (LNHA) failed to ensure resident safety by allowing the use of portable space heaters in resident rooms while the facility's boilers were not operational. The Maintenance Director (MD) informed the LNHA about the non-operational boilers, and as a temporary measure, portable space heaters were purchased and placed in resident rooms. This decision was made despite the known fire hazard associated with using space heaters, especially in rooms with cognitively impaired residents and those using oxygen. The deficiency was identified during a survey conducted on 12/17/2024, where it was noted that the facility had 38 cognitively impaired residents and 10 residents prescribed oxygen at the time the space heaters were used. The LNHA acknowledged awareness of the regulations prohibiting space heaters due to fire risks but justified the action as necessary for resident comfort and safety during the emergent situation. The use of space heaters in such conditions placed all residents at risk for an Immediate Jeopardy (IJ) situation. The facility's Emergency Preparedness Plan for Fire Prevention outlined the responsibility of all personnel to report and correct hazardous conditions promptly. However, the use of space heaters in resident rooms, especially under the circumstances described, was a clear violation of this policy. The LNHA's decision to use space heaters, despite understanding the associated risks and regulations, directly contributed to the deficiency identified by the surveyors.
Removal Plan
- Education for the LNHA and MD on not using space heaters in the facility
- Education for all staff on not using the space heaters in the facility
Failure to Report Misappropriation of Narcotic Medication to BON
Penalty
Summary
The facility failed to notify the Board of Nursing (BON) about a Licensed Practical Nurse/Supervisor (LPN/S) who was under investigation for misappropriation of residents' narcotic medication. The investigation began when a nurse discovered unidentifiable signatures on the declining inventory form for a resident's Oxycodone. Further investigation revealed similar discrepancies for two other residents, all of which pointed to the LPN/S who had access to the medication carts during the relevant shifts. Despite notifying the police and the DEA, the facility did not report the incident to the BON as required by their policies and state regulations. The Director of Nursing (DON) and the Human Resource Director (HRD) attempted to meet with the LPN/S to discuss the investigation, but the LPN/S did not attend the scheduled meeting and did not respond to follow-up communication. Consequently, the HRD sent a certified letter to the LPN/S, considering her absence as a voluntary resignation. The facility's policies on incident reporting, abuse, neglect, and controlled substance administration were reviewed, and it was confirmed that the BON had not been notified about the incident. The Regional Director of Clinical Services (RDCS), who was the DON at the time of the incident, acknowledged that the investigation was completed and reported to the Department of Health, the police, and the DEA. However, the RDCS admitted that the BON was not notified because there was no concrete proof that the LPN/S took the medications, even though she was the only one with access to all the carts. The administrative team later acknowledged that the incident should have been reported to the BON, and a report was eventually submitted to the BON after the survey team reviewed the case.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to ensure that the medication error rates were not 5% or greater. During a morning medication administration observation, two nurses administered medications to four residents, resulting in 37 opportunities and two errors, which calculated to a medication administration error rate of 5.41%. This deficiency was identified for one resident who was administered medications by one of the two nurses observed. Specifically, the Licensed Practical Nurse (LPN) administered Icosapent Ethyl and Darolutamide to the resident without ensuring the resident had eaten, despite the medications' requirements to be taken with food. The LPN acknowledged that the resident had not eaten since the previous night and that the resident's breakfast tray was untouched as the resident was waiting for food from home. The resident's Electronic Medication Administration Records (eMARs) clearly indicated that both medications should be given with meals. The facility's policy on medication administration, revised on 5/30/23, and the undated PharmACCURATE Medication Pass policy provided by the Director of Nursing, both emphasized the importance of administering medications as ordered and with appropriate food and fluids. The LPN admitted to the surveyor that the medications should have been held until the resident had eaten.
Failure to Complete and Submit MDS in Accordance with Federal Guidelines
Penalty
Summary
The facility failed to complete and submit a Minimum Data Set (MDS) for a resident in accordance with federal guidelines. The deficiency was identified during a surveyor's observation, interview, and record review. The resident, who had been admitted to the facility with chronic systolic heart failure, acute and chronic respiratory failure with hypoxia, and chronic kidney disease stage 3, was observed in bed with oxygen via nasal cannula. The resident had been admitted to and readmitted from the hospital multiple times, but the MDS tracking records for one of these hospitalizations were not completed within the required timeframe. The MDS Coordinator acknowledged that the entry and discharge tracking records for the resident's hospitalization on 11/24/23 were not completed. The coordinator explained that she typically completed these records the day of admission, readmission, or discharge, or the next day if she was not in the building. However, she missed the entry and discharge tracking for the specified date. The facility's policy requires that entry tracking be completed and submitted within seven days and discharge assessments within 14 days, which was not adhered to in this case.
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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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Nursing homes near Cranbury
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cranbury Center | 2 mi | ★★★★★ | 10 | 2 |
| Gardens At Monroe Healthcare And Rehabilitation, T | 2.8 mi | ★★★★★ | 0 | 0 |
| Meadow Lakes | 4 mi | ★★★★★ | 0 | 0 |
| Village Point | 4.4 mi | ★★★★★ | 1 | 1 |
| Complete Care At Park Place Llc | 5.7 mi | ★★★★★ | 16 | 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.