Inspection Reports for The Elms Rehab And Healthcare Center Of Cranbury
61 Maplewood Avenue, Cranbury, NJ, 08512
Back to Facility ProfileInspection Report Summary
The most recent inspection on November 20, 2025, did not identify any deficiencies. Earlier inspections showed a pattern of issues primarily related to staffing ratios and medication management, with some findings involving resident safety and documentation. Notably, in December 2024, an Immediate Jeopardy was cited due to the use of portable space heaters posing a fire hazard, which was resolved through removal and staff education. Several complaint investigations found substantiated deficiencies, especially concerning staffing shortfalls and medication error rates, but no fines or license actions were listed in the available reports. The facility’s record shows some improvement in recent inspections, with the latest survey free of citations after prior mixed results.
Deficiencies (last 6 years)
Deficiencies (over 6 years)
2.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
46% better than New Jersey average
New Jersey average: 5.2 deficiencies/yearDeficiencies per year
4
3
2
1
0
Census
Latest occupancy rate
96 residents
Based on a April 2025 inspection.
Occupancy over time
Notice
Deficiencies: 0
Date: Nov 20, 2025
Visit Reason
This document serves to inform individuals about the privacy practices of NJDHSS, including how their medical information may be used and disclosed, and their rights related to this information.
Findings
The notice details the types of information covered, reasons for use and disclosure of health information, individuals' rights to access and control their information, and the legal duties of NJDHSS to protect privacy.
Report Facts
Effective date: 2011
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director | NJDHSS Privacy Officer named as contact for privacy practices |
Inspection Report
Complaint Investigation
Census: 96
Deficiencies: 1
Date: Apr 30, 2025
Visit Reason
The inspection was conducted based on complaints NJ183359 and NJ185801 to investigate compliance with staffing ratio requirements and other regulatory standards.
Complaint Details
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.
Findings
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.
Deficiencies (1)
Failure to ensure staffing ratios were met for 14 of 14 day shifts, specifically deficient CNA staffing.
Report Facts
Census: 96
Deficient day shifts: 14
Required CNAs per day shift: 12
Actual CNAs per day shift: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Re-educated on minimum staffing requirements as part of corrective action. | |
| Director of Nursing | Re-educated on minimum staffing requirements as part of corrective action. | |
| Staffing Coordinator | Re-educated on minimum staffing requirements as part of corrective action. |
Inspection Report
Abbreviated Survey
Census: 96
Deficiencies: 0
Date: Feb 13, 2025
Visit Reason
A Focused Infection Control survey was conducted on 02/13/25 to assess the facility's compliance with infection control regulations.
Findings
The facility was found to be in substantial compliance with 42 CFR 483 subpart B during the infection control survey.
Report Facts
Sample Size: 8
Inspection Report
Complaint Investigation
Census: 101
Deficiencies: 2
Date: Dec 17, 2024
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (2)
Failure to ensure resident safety by allowing the use of portable space heaters in resident rooms while boilers were not operational, creating a fire hazard and placing residents at risk for Immediate Jeopardy.
Failure to comply with staffing ratios for certified nurse aides for 7 of 14 day shifts reviewed.
Report Facts
Census: 101
Sample Size: 48
Deficiencies cited: 2
Certified Nurse Aide staffing: 7
Portable space heater boxes observed: 46
Inspection Report
Annual Inspection
Census: 89
Deficiencies: 4
Date: Mar 7, 2024
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Complaint Details
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.
Findings
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.
Deficiencies (4)
Failure to notify the Board of Nursing for a Licensed Practical Nurse under investigation for misappropriation of residents' medication.
Failure to complete and submit Minimum Data Set (MDS) assessments in accordance with federal guidelines for one resident.
Medication error rate of 5.41% observed during medication administration.
Failure to accurately post staffing information including staff-to-resident ratios on the resident care staffing report.
Report Facts
Census: 89
Sample size: 22
Medication error rate: 5.41
Number of medication administration opportunities observed: 37
Number of medication errors observed: 2
Staffing numbers: 2
Staffing numbers: 8
Staffing numbers: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN/S #1 | Licensed Practical Nurse/Supervisor | Named in medication misappropriation investigation and failure to notify Board of Nursing. |
| DON #1 | Director of Nursing | Provided investigation file and participated in survey team meetings. |
| DON #2 | Director of Nursing | Acknowledged investigation completion and failure to notify Board of Nursing. |
| HRD | Human Resource Director | Reached out to LPN/S #1 for meeting regarding investigation. |
| RDCS | Regional Director of Clinical Services | Confirmed notification to DEA and police but not Board of Nursing. |
| RDO | Regional Director of Operations | Participated in exit conference with survey team. |
| Staffing Coordinator | Responsible for completing resident staffing care report and interviewed regarding staffing postings. |
Inspection Report
Complaint Investigation
Census: 100
Deficiencies: 0
Date: Apr 1, 2023
Visit Reason
A complaint survey was conducted on behalf of the New Jersey Department of Health based on multiple complaints received.
Complaint Details
Complaints NJ00159136, NJ00159370, NJ00159714, NJ00160338, NJ00160906, and NJ00161012 were investigated during the survey.
Findings
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.
Report Facts
Sample size: 8
Inspection Report
Complaint Investigation
Census: 98
Deficiencies: 3
Date: Dec 22, 2022
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (3)
Failure to report injury of unknown origin to NJDOH and follow facility policy on abuse investigation and reporting for 2 of 6 residents.
Failure to consistently document Activities of Daily Living (ADL) status and care provided for 4 of 4 residents reviewed.
Failure to maintain required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey for 9 of 14 days reviewed.
Report Facts
Census: 98
Sample Size: 6
Days with deficient CNA staffing: 9
Residents: 102
Required CNA staffing: 13
Actual CNA staffing: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA #1) | Witnessed and reported injury to nurse, involved in abuse investigation | |
| Registered Nurse (RN #1) | Notified of injury and reported incident to Director of Nursing | |
| Director of Nursing (DON) | Concluded no evidence of intentional mishandling, confirmed reporting policies | |
| Nurse Practitioner (NP) | Assessed Resident #1 and ordered X-ray | |
| Licensed Practical Nurse (LPN #1) | Reported incident involving Resident #3, provided verbal statement | |
| Certified Nursing Assistant (CNA #4) | Reported incident involving Resident #3 | |
| Administrator | Acknowledged staffing deficiencies and reporting requirements | |
| Staffing Coordinator | Responsible for staffing schedules and addressing CNA staffing needs | |
| Licensed Practical Nurse/Unit Manager (LPN/UM) | Responsible for ensuring ADL documentation completion |
Inspection Report
Complaint Investigation
Census: 101
Deficiencies: 2
Date: Sep 25, 2022
Visit Reason
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.
Complaint Details
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.
Findings
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.
Deficiencies (2)
Facility failed to maintain a medication error rate below 5%, with an 8% error rate observed during medication passes involving Resident #8.
Facility failed to maintain direct care staff-to-resident ratios as mandated by New Jersey State Law on 15 out of 84 shifts reviewed.
Report Facts
Census: 101
Sample Size: 9
Medication Error Rate: 8
Medication Opportunities Observed: 25
Medication Errors Detected: 2
Shifts with Staffing Deficiency: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Administered incorrect medication to Resident #8 |
| Regional Director of Nursing Services | Regional Director of Nursing Services | Provided interview confirming medication administration policies |
| Director of Nursing | Director of Nursing | Completed nurse education on medication administration policy and responsible for monitoring audits |
| Nursing Home Administrator | Nursing Home Administrator | Reported on staffing challenges and efforts to meet mandated staffing ratios |
Document
Deficiencies: 0
Date: Nov 19, 2021
Visit Reason
This document is not an inspection report or regulatory document; it is an instruction for opening a PDF portfolio.
Findings
No inspection findings or regulatory content present.
Inspection Report
Life Safety
Capacity: 120
Deficiencies: 4
Date: Nov 19, 2021
Visit Reason
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.
Findings
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.
Deficiencies (4)
Corridor doors in 4 resident rooms (108, 213, 224, 227) did not latch properly, restricting the ability to confine fire and smoke.
Bathroom ventilation fans in 21 of 52 resident rooms were not functioning properly, failing to provide adequate ventilation.
Highly flammable untreated combustible decorations (2 large dolls made of dried straw and 1 bale of hay) were found in the egress corridor.
Oxygen storage room had full and empty oxygen cylinders stored together without proper segregation or labeling.
Report Facts
Certified beds: 120
Resident rooms with doors not latching: 4
Resident rooms with non-functioning bathroom ventilation: 21
Combustible decorations observed: 3
Oxygen tanks improperly stored: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed and confirmed deficiencies related to door latching, ventilation fans, combustible decorations, and oxygen tank storage | |
| Administrator | Informed of findings at Life Safety Code exit conference |
Inspection Report
Routine
Census: 92
Deficiencies: 0
Date: Apr 14, 2021
Visit Reason
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.
Findings
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.
Report Facts
Sample size: 8
Inspection Report
Abbreviated Survey
Census: 91
Deficiencies: 1
Date: Feb 12, 2021
Visit Reason
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.
Findings
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.
Deficiencies (1)
Failure to ensure the visiting Physician adhered to facility infection control policies by accessing a restricted resident unit through a temporary barrier separation.
Report Facts
Census: 91
Sample size: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Physician | Named in infection control deficiency for breaching restricted area protocol | |
| Registered Nurse | Interviewed regarding proper access protocol to the restricted unit | |
| Facility Administrator | Provided information about the restricted unit access and barrier | |
| Infection Preventionist | Responsible for monitoring compliance with infection control policies |
Inspection Report
Routine
Census: 94
Deficiencies: 0
Date: Dec 8, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the New Jersey Department of Health to assess compliance with infection control regulations.
Findings
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.
Report Facts
Sample size: 13
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