Elmora Hills Health & Rehabilitation Center

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to maintain a medication error rate below 5%. During the morning medication (med) administration observation on 12/8/25, 2 surveyors observed 2 nurses administer 33 doses of medication to 4 residents and there were 2 errors which resulted in a medication error rate of 6.06%. The deficient practice was identified for 1 of 4 unsampled residents (Resident #130), that was administered meds by 1 of 2 nurses observed. The deficient practices were evidenced by the following: [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to store potentially hazardous food and maintain sanitation in a safe and consistent manner to prevent food borne illness in 2 of the 3 pantries reviewed (the 2 North and 3rd floor pantries). This deficient practice was evidenced by the following:On 12/10/25 at 10:55 AM, in the presence of the Charge Nurse (CN #1), the surveyor inspected the 2 North pantry and observed the following: a transparent plastic container with a red colored lid in a plastic bag, with a white sticker that had a handwritten label with a resident's name and a room number. The surveyor and the CN were not able to read the current date and the use by date was 12/7/25. The surveyor observed the inside of the microwave that had a paper towel on the plate and the backwall had brown colored stains. [...]

Inspectors wroteBased on observation, interview, and other facility documentation, it was determined that the facility failed to a.) provide a hands-free garbage container in the laundry room and b.) follow appropriate infection control protocol for hand washing after removing personal protective equipment (PPE). This deficient practice was identified during the tour of the laundry room and was evidenced by the following:On 12/09/2025 at 10:56 AM, during a tour of the laundry room with the Housekeeping Director (HSKD), the surveyor observed a blue garbage container with a white sheet covering the top. The HSKD acknowledged the missing lid. The surveyor asked how garbage was placed in the garbage can after handwashing was performed. The HSKD stated staff washed their hands at the sink and used a dry paper towel to move the sheet and place the garbage in the container. [...]

Inspectors wroteBased on the interview and review of facility documentation, it was determined that the facility failed to ensure that facility wide assessment included the resources required to establish policies and procedures for the management of staffing contingency plan and linen and/or supplies in order to meet the requirements and needs of all residents in the facility. This failure had the potential to affect all 186 residents who currently live in the facility. This deficient practice was evidenced by the following: During the entrance conference on 8/14/24 at 9:50 AM, Surveyor #1 (S#1) requested from the Licensed Nursing Home Administrator (LNHA) and the Director of Nursing (DON) a copy of the Facility Assessment (FA). Both the LNHA and DON stated that the facility's census (the number of residents currently under the care of a specific facility) was 186. [...]

Inspectors wroteBased on observation, interview, review of medical records, and other pertinent facility documentation, it was determined that the facility failed to a.) follow appropriate hand hygiene and use of personal protective equipment (PPE) practices for four (4) of nine (9) staff (two Recreation Staff, one Certified Nursing Aide, and one Hospice Aide) and b.) follow appropriate infection control practices to prevent the potential spread of infection for two (2) of two (2) rooms observed during laundry area tour in accordance with the Center for Disease Control and Prevention (CDC) guidelines and facility's policy. This deficient practice was evidenced by the following: According to the CDC Clinical Safety: Hand Hygiene for Healthcare Workers dated 02/27/24 revealed: [...]

Inspectors wroteBased on interview, and review of pertinent facility documents, it was determined that the facility failed to ensure facility staff had mandatory training that outlined and informed staff of the elements and goals of the facility's QAPI (quality assurance and performance improvement) program for five (5) of five (5) Certified Nurse Assistants (CNAs) reviewed for mandatory education. This deficient practice was evidenced by the following: On 8/22/24 the surveyor reviewed the annual in-service education hours for five randomly selected CNA files, which were provided by the facility. The Employee In-service Record showed the following: CNA#1 had a hire date of 7/30/18. According to the Topic on the Inservice Record and Certificates of Completion, CNA #1 did not have QAPI training. CNA#2 had a hire date of 5/22/23. [...]

Inspectors wroteBased on interview, and review of pertinent facility documents, it was determined that the facility failed to ensure facility staff had mandatory training that outlined and informed staff of the elements and goals of the facility's Compliance and Ethics training for five (5) of five (5) Certified Nurse Assistants (CNAs) reviewed for mandatory education. This deficient practice was evidenced by the following: On 8/22/24, the surveyor reviewed the annual in-service education hours for five randomly selected CNA files, which were provided by the facility. The Employee In-service Record showed the following: CNA#1 had a hire date of 7/30/18. According to the the Inservice Record and Certificates of Completion, CNA #1 did not have Compliance and Ethics training. CNA#2 had a hire date of 5/22/23. [...]

Inspectors wroteBased on observation, interview, record review, and review of other facility documentation, it was determined the facility failed to ensure accurate documentation and review of a resident's advance directives for one (1) of two (2) residents (Resident #25) reviewed. This deficient practice was evidenced by the following: The surveyor reviewed the hybrid (electronic and paper) medical records of Resident #25. According to the admission Record (a summary of important information about the resident) Resident #25 was admitted with diagnoses that included but were not limited to, chronic obstructive pulmonary disease, dementia, and hypertension. A comprehensive Minimum Data Set (MDS), an assessment tool to facilitate the management of care, dated 7/18/24, indicated the facility assessed the resident's cognition using a Brief Interview Mental Status (BIMS) test. [...]

Inspectors wroteBased on interview and review of pertinent documentation provided by the facility it was determined that the facility failed to ensure licensed staff credentials were verified upon hire. This deficient practice was identified for two (2) of five (5) newly hired licensed staff reviewed, (Staff #8 and #10). This deficient practice was evidenced by the following: On 8/22/24, the surveyor reviewed ten randomly selected new employee files. The review for license verification for two of the new licensed employees revealed the following: 1. Staff #8, an Administrator, hired 8/01/22. The surveyor was unable to locate a license verification in the employee file. There was no documented evidence that Staff #8's license was verified prior to the date of hire (doh). 2. [...]

Inspectors wroteBased on observation, interview, and record review it was determined that the facility failed to accurately code the Minimum Data Set (MDS), an assessment tool used to facilitate the management of care, in accordance with federal guidelines for one (1) of 38 residents, Resident #111, reviewed for accuracy for MDS coding. This deficient practice was evidenced by the following: On 8/14/24 at 10:56 AM, the surveyor observed an EBP (enhanced barrier precaution) sign posted outside the door of the resident. Both the Licensed Practical Nurse (LPN) and the surveyor inside the resident's room observed Resident #111 with continuous oxygen (O2) via the laryngeal opening with a mask, attached to a humidified concentrator (a medical device that provides supplemental O2) at 4 LPM (four liters per minute). [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to promptly notify the physician of a medication being consistently not administered to a resident due to limits on the physician's order (hold parameter), document the physician's notification, and the physician's response. This deficient practice was identified for one (1) of 38 residents (Resident #190) reviewed, according to the standards of clinical practice. This 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: [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to a.) follow the physician's order (PO) with regard to hypoglycemic protocol, b.) clarify the PO regarding tube feeding (TF) and insulin sliding coverage orders, and c.) ensure staff followed protocol for accurate and timely documentation for one (1) of three (3) residents, Resident #58, reviewed for care and treatment of TF and hypoglycemic protocol according to facility's policies and standards of clinical practice. This 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: [...]

Inspectors wroteBased on observation, interview, record review, and review of pertinent facility documents, it was determined that the facility failed to a.) maintain infection control practices to reduce the risk of infection during a pressure ulcer (PU) treatment and perform a PU risk assessment quarterly for one (1) of four (4) residents (Resident #131) and b.) ensure that comprehensive assessment was done and documented to reflect the skin impairment of one (1) of four (4) residents reviewed for PU/injury (Resident #164) according to standards of clinical practice and facility policy. The deficient practice was evidenced by the following: Reference: National Pressure Injury Advisory Panel's Pressure Injury Prevention Points included the following: Risk Assessment Consider bedfast and chairfast individuals to be at risk for development of pressure injury. [...]

Inspectors wroteBased on observations, interviews, record review and review of other pertinent facility provided documentation, the facility failed to ensure a fall risk assessment was done quarterly in accordance with their facility policy for one (1) of four (4) residents reviewed for accidents. The deficient practice was evidenced by the following: On 8/19/24 at 9:13 AM, the surveyor observed Resident #161 asleep in a low to floor bed. A review of Resident #131's admission Record or face sheet (an admission summary) reflected that the resident was admitted to the facility with diagnoses which included but were not limited to fracture of left femur (broken thighbone), hypertension (high blood pressure) and cerebral infarction (also known as an ischemic stroke, is the pathologic process that results in an area of necrotic tissue in the brain). [...]

Inspectors wroteBased on observation, interview, record review and review of other pertinent facility documentation, it was determined that the facility failed to administer Tube Feedings per Physician's order (PO). This deficient practice was identified for one (1) of three (3) residents (Resident #48) reviewed for receiving nutrition via Tube Feeding (TF) and was evidenced by the following: On 8/14/24 at 10:49 AM, the surveyor entered Resident #48's room and observed the resident sitting in their wheelchair (w/c), and non-verbal. The surveyor observed that the resident had a TF (nutrition received through a flexible tube surgically inserted into the stomach) formula hanging on a pole, attached to a TF pump, and infusing at a rate of 90 ml/hr (milliliters per hour). On 8/15/24 at 12:36 PM, the surveyor observed the resident in their room, sitting in their w/c and a visitor was sitting next to them. [...]

Inspectors wroteREPEAT DEFICIENCY Based on observation, interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to ensure the necessary respiratory care and services of residents that were receiving oxygen, according to the standard of clinical practice and facility's policy and procedure, specifically a.) the posting of cautionary and safety signs indicating the use of oxygen were utilized for residents that received oxygen therapy, b.) that respiratory equipment were stored in accordance with facility policy and infection control measures for one (1) of two (2) residents reviewed for respiratory care (Resident #66), c.) administer oxygen therapy according to the physician's order for one (1) of two (2) residents, Resident #111, reviewed for respiratory care, and d.) ensure staff followed the appropriate hand hygiene and use of [...]

Inspectors wroteBased on the interview, record review, and review of other pertinent facility documentation, it was determined that the facility failed to ensure: a.) that the Physician's Order (PO) for pain management was clarified according to the appropriate pain level for one (1) of two (2) residents, Resident #111, and b.) the PO for as needed pain medications were separated according to indications for two (2) of two (2) residents, Residents #111 and #164, reviewed for pain management according to standards of clinical practice and facility policy. 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: [...]

Inspectors wroteBased on interview and review of pertinent facility documents, it was determined that the facility failed to ensure a.) a non-certified Nurse Aide (NA) did not continue to work as an NA after the specified 120 days for one (1) of two (2) NAs reviewed, (NA #1) and b.) there was a delineated policy and/or program in place for the hiring of non-certified NAs. This deficient practice was evidenced by the following: Reference: State of New Jersey (NJ) Department of Health memo dated April 21, 2023, sent to Nursing Homes included the following: On February 27, 2023, the Centers for Medicare and Medicaid Services (CMS) announced that all nurse aide emergency training waivers will terminate at the end of the Federal Public Health Emergency (PHE). The PHE is expected to end on May 11, 2023. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility documentation, it was determined that the facility failed to ensure that the resident did not receive an unnecessary medication for one (1) of thirty-six (38) residents reviewed, (Resident #147). The deficient practice was evidenced by the following: On 8/15/24 at 11:18 AM, the surveyor observed Resident #147 in a wheelchair in hallway. The resident agreed to speak with the surveyor. During the brief interview, the resident stated they were very happy at the facility and was here because of a fall at home. The surveyor asked if the resident has any pain or other complaints. The resident did not state anything specific but did refer to some dizziness and headache at times. The surveyor reviewed Resident #147's electronic medical record (EMR) which revealed the following: [...]

Inspectors wroteBased on observation, interview, and review of pertinent documents, it was determined that the facility failed to ensure that medications were stored and labeled appropriately. This deficient practice was identified in two (2) of four (4) medication carts inspected on two (2) of three (3) floors. This deficient practice was evidenced by the following: On 8/19/24 at 10:25 AM, the surveyor conducted the Medication Storage and Labeling task. The surveyor inspected a medication (med) cart located on the third-floor north unit in the presence of Licensed Practical Nurse #1 (LPN#1) assigned to that med cart. The surveyor observed nine (9) medications (meds) of various sizes, shapes and colors located on the bottom of the second drawer of the med cart. The surveyor showed the loose meds to the LPN and asked if those meds should be there. The LPN stated no, there should not be any loose meds. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to ensure palatable and appetizing temperature of food for one (1) lunch meal observed on one (1) of four (4) nursing units (Third floor unit). This deficient practice was evidenced by the following: Reference: Sanitation in Retail Food Establishments and Food and Beverage Vending Machines N.J.A.C. 8:24-3.5 Limitation of growth of organisms of public health concern (f) Except during preparation, cooking, or cooling, or when time is used as the public health control as specified under (g) below, potentially hazardous food shall be maintained: 1. At 135°F or above, except that roasts cooked to safe cooking temperatures or reheated as specified under N.J.A.C. 8:24-3.4(g)5 may be held at a temperature of 130°F; or 2. At refrigeration temperatures. [...]

Inspectors wroteBased on observation, interview and policy review it was determined that the facility failed to a.) store potentially hazardous foods in a manner to prevent food borne illness, b.) failed to sanitize and air-dry dishware, steam table pans and silverware in a manner to prevent microbial growth and c.) failed to maintain the kitchen environment and equipment in a sanitary manner to prevent contamination from foreign substances and potential for the development of a food borne illness. This deficient practice was evidenced by the following: On 3/28/22 at 9:48 AM, in the presence of the Food Service Director (FSD), the surveyor observed the following: 1. The surveyor observed a handwashing sink next to a food preparation area and there was no barrier between them to prevent cross-contamination. 2. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to obtain a physician's order for the administration of continuous oxygen. This was found with 1 of 1 residents reviewed for respiratory treatment, Resident # 121. The deficient practice was evidenced by the following: On 3/28/22 11:39 AM, the surveyor observed Resident #121 seated in a wheelchair in the dining room during an activity. The resident had oxygen (O2) going at 2 l/m (liters/minute) by way of (via) nasal cannula. On 3/30/22 at 10:49 AM, the surveyor observed the resident in the dining room seated in a wheelchair with O2 being delivered at 2 l/m via nasal cannula. At 11:29 AM, the surveyor asked the activity aide (AA) who was assigned to the area if Resident #121 always used O2. The AA stated, yes, [the resident] always has O2 on. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to medications were administered in a timely manner in accordance with professional standards of nursing practice for 1 of 38 residents reviewed (Resident # 103). This 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: The practice of nursing as a licensed practical nurse is defined as performing tasks and responsibilities within the framework of case finding; reinforcing the patient and family teaching program through health teaching, health counseling, and provision of supportive and restorative care, under the direction of a registered nurse or licensed or otherwise legally authorized physician or dentist. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to a.) ensure that the applications of assistive devices were provided as ordered and b.) provide an appropriate Restorative Nursing Program (RNP) for 2 of 6 residents (Resident #20 and #115) reviewed for limited range of motion (ROM) according to the facility's policy and procedures and standards of clinical practice. This deficient practice was evidenced by the following: 1. On 3/28/22 at 10:20 AM, the surveyor observed that Resident #20 was not in their room. At that time, the Licensed Practical Nurse #1/Charge Nurse (LPN #1/CN) informed the surveyor that Resident #20 was probably self-propelling in the unit. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to a.) ensure that weekly weights were done, and b.) re-evaluate and modify the care plan goal to reflect the current condition of the resident for 1 of 5 residents reviewed for nutrition (Resident #57). This deficient practice was evidenced by the following: On 3/28/22 at 10:27 AM, the surveyor observed Resident#57 seated in a gerichair (which combines the features of a comfy recliner and a transport wheelchair) with a tube feeding ( a medical device used to provide nutrition to people who cannot obtain nutrition by mouth, unable to swallow safely, or need nutritional supplementation) infusing at 75 ml/hr (milliliters/hour) with 715 ml total volume infused. [...]

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to 1.) consistently ensure the Dialysis Progress Note was completed by both the facility and dialysis center and 2.) failed to monitor residents returning from the dialysis center for access site and vital signs. The deficient practice was observed for 4 of 4 residents (Resident #69, #71, #15 and #99) reviewed. The deficient practice was evidenced by the following: 1. On 3/28/22 at 11:23 AM, the surveyor observed Resident #69 lying in bed, awake and alert and able to be interviewed. Resident #69 stated that he/she goes to dialysis three days a week, on Monday, Wednesday and Friday. The resident stated that he/she usually returns to the facility approximately 6 PM. The resident further stated that the nurses heat up the dinner meal upon returning from the dialysis center. [...]

Inspectors wroteBased on interview and record review, it was determined that the facility failed to notify resident families or resident representatives (RR), and the Ombudsman's office in writing for a facility-initiated transfer to the hospital for 8 of 8 residents (Resident #69, #15, #41, #607, #99, #144, #57 and #21) reviewed for hospitalization. The deficient practice was evidenced by the following: The surveyors reviewed the hybrid medical records (paper and electronic) that revealed facility-initiated hospital transfers had occurred without written notification to the families and Ombudsman's office for the following residents: 1. According to the Discharge Minimum Data Set (MDS) an assessment tool dated 12/29/21, Resident #69 was transferred to the hospital with anticipated return to the facility. [...]