Inspection Reports for The Elms Rehab And Healthcare Center Of Cranbury

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The inspection was conducted based on complaints NJ183359 and NJ185801 to investigate compliance with staffing ratio requirements and other regulatory standards.

The facility was found not in compliance with New Jersey Administrative Code 8:39 regarding staffing ratios, failing to meet minimum Certified Nurse Aide (CNA) staffing requirements on 14 of 14 day shifts during the two weeks prior to the survey. The facility was cited for deficient CNA staffing but no residents were identified as directly affected.

Complaint numbers NJ183359 and NJ185801 triggered the investigation. The facility was found deficient in staffing ratios but was in substantial compliance overall. No residents were identified as affected by the deficient practice.

A Focused Infection Control survey was conducted on 02/13/25 to assess the facility's compliance with infection control regulations.

The facility was found to be in substantial compliance with 42 CFR 483 subpart B during the infection control survey.

The inspection was conducted as a complaint investigation based on complaints NJ00181255 and NJ00181471 regarding resident safety and use of portable space heaters in resident rooms when boilers were non-operational.

The facility was found not in substantial compliance due to failure to ensure resident safety by using portable space heaters in resident rooms despite fire hazard risks. An Immediate Jeopardy (IJ) was identified related to the use of space heaters. The facility implemented a removal plan and education for staff. Another deficiency was found related to staffing ratios not being met for certified nurse aides during the review period.

Complaint numbers NJ00181255 and NJ00181471 triggered the investigation. The Immediate Jeopardy was identified on 12/17/2024 at 6:06 PM and was reported to the appropriate authorities. The IJ began on 12/8/2024 and continued through 12/18/2024 when the facility submitted an acceptable Removal Plan. The noncompliance remained as a level D on 12/20/2024 but was not an IJ due to staff education and removal of space heaters.

A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.

Deficiencies were cited related to failure to notify the Board of Nursing about a Licensed Practical Nurse under investigation for medication misappropriation, failure to complete and submit Minimum Data Set (MDS) assessments timely, medication error rate exceeding 5%, and inaccurate posting of staffing information.

Complaint NJ #159517, #161104, #161105, #161107, #163603, #166090, #166352, #166620, #167003, #168446. The complaint investigation revealed failure to notify the Board of Nursing regarding a Licensed Practical Nurse under investigation for medication misappropriation.

A complaint survey was conducted on behalf of the New Jersey Department of Health based on multiple complaints received.

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.

Complaints NJ00159136, NJ00159370, NJ00159714, NJ00160338, NJ00160906, and NJ00161012 were investigated during the survey.

The inspection was conducted based on complaints NJ159278, NJ159279, and NJ159280 regarding compliance with 42 CFR Part 483, Subpart B for Long Term Care Facilities.

The facility was found non-compliant for failing to report injuries of unknown origin timely to the New Jersey Department of Health for two residents, and failing to consistently document Activities of Daily Living (ADL) care for four residents. Additionally, the facility failed to maintain the required minimum direct care staff-to-resident ratios for 9 of 14 days reviewed.

The complaint investigation revealed failure to report injuries of unknown origin timely and failure to follow facility policies on abuse investigation and reporting for residents #1 and #3.

The inspection was conducted as a complaint investigation based on multiple complaint intakes (NJ151488, NJ152377, NJ154715, NJ157439, NJ154751) to assess compliance with federal and state regulations for long-term care facilities.

The facility was found not in compliance with medication error rate requirements, with an 8% error rate observed during medication passes, and failed to maintain mandated direct care staff-to-resident ratios on multiple shifts. Corrective actions and monitoring plans were outlined in the provider's plan of correction.

The complaint investigation was based on multiple complaint intakes (NJ151488, NJ152377, NJ154715, NJ157439, NJ154751). The medication error rate deficiency was substantiated with an 8% error rate found. The staffing deficiency was also substantiated with documented failure to meet minimum staffing ratios on multiple shifts.

This document is not an inspection report or regulatory document; it is an instruction for opening a PDF portfolio.

No inspection findings or regulatory content present.

A Life Safety Code Survey was conducted by the New Jersey Department of Health to assess compliance with Medicare/Medicaid participation requirements related to fire safety and life safety codes.

The facility was found to be noncompliant with several Life Safety Code requirements including corridor doors not latching properly, malfunctioning bathroom ventilation fans in multiple resident rooms, presence of combustible decorations in egress corridors, and improper storage of oxygen cylinders with full and empty tanks not segregated or labeled.

A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations and recommended COVID-19 practices.

The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented the CMS and CDC recommended practices for COVID-19.

A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with CMS and CDC recommended practices for COVID-19 infection control.

The facility was found not to be in compliance with infection control regulations, specifically failing to ensure that the visiting Physician adhered to facility policies designed to prevent infection spread by improperly accessing a restricted resident unit area.

A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations.

The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices for COVID-19.