Elmwood Hills Healthcare Center LLC

Inspectors wroteComplaint #: 2629258Based on interviews, review of medical records, and other pertinent facility documentation on 10/9/2025 and 10/10/25, it was determined that the facility failed to provide adequate supervision for a resident (Resident #2) who was cognitively impaired with documented history of exit seeking behaviors; and who eloped out of the facility building on 9/28/2025. The deficient practice was identified for 1 of 3 residents reviewed (Resident #2). A review of Facility Reportable Event (FRE) revealed that on 9/28/2025, a Licensed Practical Nurse (LPN #1) asked a Certified Nursing Assistant (CNA #1) to use her employee identification (ID) badge to swipe open the locked door on the second floor secured unit for Resident #2, which CNA #1 did provide. This allowed Resident #2 to exit the unit because both CNA #1 and LPN #1 thought the resident was a visitor. [...]

Inspectors wroteComplaint #: NJ176228 Based on observation, interview, record review, and review of facility documents, it was determined that the facility failed to a.) follow a physician's order to apply a urinary catheter stabilization device, b.) accurately identify a resident's urinary stabilization device was applied in the electronic medical record (EMR), c.) properly identify a resident's incontinence status in the EMR, and d.) monitor urinary output according to the physician's orders in the EMR. This deficient practice was identified for 2 of 2 Residents (Resident #104 and #196) reviewed for urinary catheters and 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, record review, and review of pertinent facility documents, it was determined that the facility failed to complete a discharge Minimum Data Set (MDS), an assessment tool, as required for 1 of 1 resident (Resident #275) system selected for MDS over 120 days. This deficient practice was evidenced by the following: The MDS is a comprehensive federally mandated process for clinical assessment of all residents that should be completed and submitted to the Quality Measure System. The facility must complete the assessment at discharge and electronically transmit the MDS no later than 14 days after completing the assessment. The surveyor reviewed the electronic medical record (EMR) for Resident #275. [...]

Inspectors wroteComplaint #: NJ165862, NJ184181 Based on observation, interview, record review, and review of facility-provided documentation, it was determined that the facility failed to ensure that incontinence care was provided to a dependent resident in a timely manner. This deficient practice was identified for 1 of 4 residents (Resident #247) reviewed for Activities of Daily Living (ADL) care and was evidenced by the following: On 4/30/25 at 10:16 AM, during the initial tour of the 2 East Unit, the surveyor observed Resident #247 awake and alert lying in bed, the bed sheets were wet and there was a strong odor of urine in the room. At that time, the surveyor requested Licensed Practical Nurse/Unit Manager (LPN/UM #3) to check the resident for incontinence care. The resident stated, I am sure I am wet. [...]

Inspectors wroteBased on observation, interview, record review, and pertinent facility documentation, it was determined that the facility failed to ensure that treatment to prevent or reduce range of motion limitations were provided for 1 of 1 resident (Resident #11) reviewed for limited range of motion. This deficient practice was evidenced by the following: On 5/6/25 at 10:30 AM, the surveyor observed Resident #11 lying in bed in watching television. The resident's left hand was resting on the bed without a hand roll in place (which is used to prevent the fingers from contracting tightly into the palm). On 5/7/25 at 11:22 AM, the surveyor observed Resident #11 lying in bed watching television. The resident's left hand was resting on the bed without a hand roll in place. The surveyor reviewed the electronic medical record (EMR) for Resident #11. [...]

Inspectors wroteBased on observation, interview, record review, and review of facility documents, it was determined that the facility failed to ensure that oxygen was administered in accordance with a physician's order for 1 of 1 resident (Resident #146) reviewed for respiratory care. This deficient practice was evidenced by the following: On 4/30/25 at 10:23 AM, the surveyor observed Resident #146 who was seated in a wheelchair at the bedside. The resident was receiving 3.5 liters of oxygen from an oxygen concentrator (a medical device) via a nasal cannula (two prongs inserted into the nostrils with a tube that connects to an oxygen source). When interviewed, the resident stated that he/she was ordered two liters of oxygen but the oxygen concentrator was weak and they needed to turn it up. [...]

Inspectors wroteBased on interview, record review, and review of other facility documentation, it was determined that the facility failed to administer pain medication according to the physician's order for 1 of 5 residents (Resident #155) reviewed for unnecessary medications. This deficient practice was evidenced by: On 5/7/25 at 9:21 AM, the surveyor observed Resident #155 sitting in their room. When asked about pain, the resident stated he/she had chronic pain in his/her lower back from an old injury. The resident further stated that their pain was typically a level 7 out of 10, but that they received as needed pain medication that brought the pain level down to a level three (3) which was effective for the resident. The surveyor reviewed the medical record for Resident #155. [...]

Inspectors wroteComplaint # NJ00176228 Based on observation, interview, record review, and review of facility documentation, it was determined that the facility failed to maintain complete and accurate medical records in accordance with acceptable standards of practice. The facility failed to ensure a.) weekly skin assessments were accurately documented in the Treatment Administration Record (TAR) and b.) the physician's orders were followed and accurately documented the medication administration on the Medication Administration Record (MAR). This deficient practice was identified in 1of 2 residents (Resident #82) reviewed for pressure ulcer and 1of 1 resident (Resident #60) reviewed for communication and sensory problems and was evidenced by the following: 1.) On 4/30/25 at 10:34 AM, the surveyor observed Resident #82 awake and alert, lying in bed with a pressure relieving mattress on the bed. [...]

Inspectors wroteBased on interview, record review, and review of pertinent facility documents, it was determined that the facility failed to ensure that the pneumococcal vaccination was administered to a resident upon admission to the facility. This deficient practice was identified for 1 of 5 residents (Resident #72) reviewed for immunizations and was evidenced by the following: Reference: Centers for Disease Control and Prevention (CDC) Morbidity and Mortality Weekly Report Pneumococcal Vaccine for Adults Aged >19 Years: [...]

Inspectors wroteNJ Complaint #159807 Based on interviews, review of closed medical records, and review of pertinent facility documents, it was determined that the facility failed to ensure appropriate care was provided with no delay in treatment for a resident with an indwelling pleural chest catheter/tube who had a change in condition with respiratory distress on [DATE] received a chest x-ray on [DATE], and was hospitalized via emergency services prior to chest x-ray results. This deficient practice was identified for 1 of 45 residents (Resident #439) reviewed for quality of care, and was evidenced by the following: On [DATE] at 8:52 AM, the surveyor reviewed the closed medical records for Resident #439. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure appetizing and palatable temperature of food for 1 of 1 lunch meals observed on 1 of 6 nursing units (1 East). This deficient practice was evidenced by the following: On 4/10/23 at 10:14 AM, the surveyor conducted a Resident Council meeting which included six residents (Residents #87, #118, #135, #208, #212, and #260). All six residents informed the surveyor that the food was served cold on all shifts to which they attributed to short staffing. On 4/14/23 at 8:35 AM, the surveyors informed the Assistant Food Service Director (AFSD) that they wanted to observe the lunch meal service for that day including food temperatures. The AFSD acknowledged the request and stated that lunch service began at 11:15 AM. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to: a.) store, label, date and properly document and cool potentially hazardous foods to prevent food-borne illness; b.) discard potentially hazardous foods past their date of expiration; c.) ensure that dented cans were removed from storage; d.) ensure that serving trays were dried in a safe and sanitary manner prior to meal service; e.) ensure that food was served in a safe and sanitary manner to prevent contamination; f.) ensure that the dish machine in use maintained the appropriate temperature and sanitizer levels according to the manufacturer's specifications; and g.) maintain multiuse food-contact surface cutting board and can opener in a manner to prevent microbial growth. This deficient practice was evidenced by the following: [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documentation, it was determined that the facility failed to ensure that infection control practices were followed by ensuring a.) appropriate personal protection equipment was worn for residents on transmission-based precautions; b.) appropriate hand hygiene including donning (put on) and doffing (removing) of gloves and hand washing; c.) appropriate disposal of resident's garbage in the room; d.) appropriate storage of respiratory equipment; and e.) sanitizing of reusable equipment in accordance with nationally accepted guidance and facility policy. This deficient practice was identified in 4 of 6 nursing units (S1, S2, 1 West, and 1 East) with multi-disciplinary staff and was evidenced by the following: 1. [...]

Inspectors wroteNJ Complaint #157789 Based on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to report to the New Jersey State Department of Health (NJDOH) a.) an injury of unknown origin for an incident on 10/8/22; b.) an allegation of staff to resident abuse for an incident on 1/30/23; and c.) and allegation of staff to resident mistreatment on 9/24/22. This deficient practice was identified for 3 of 3 residents (Resident #15, #152, and #440) reviewed for abuse, and the evidence was as follows: 1. On 4/6/23 at 9:37 AM, the surveyor observed Resident #15 sitting in their wheelchair in their room asleep. The surveyor reviewed the medical record for Resident #15. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure the appropriate management of enteral feeding formula and piston syringes. This deficient practice was identified for 2 of 3 residents (Resident #77 and #88) reviewed for tubing feeding, and was evidenced by the following: 1. On 4/3/23 at 10:50 AM, the surveyor observed Resident #88 in bed asleep with an enteral feeding tube pump (FT; a tube surgically inserted to the stomach to provide food and nutrients) administering Jevity 1.5 (nutritional formula) at a rate of 85 milliliters (mL) per hour. The surveyor observed the 1000 mL bottle of Jevity 1.5 had approximately 300 mL of formula remaining, and the label was not filled out with the resident's name, date, or rate of infusion (mL per hour). [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined the facility failed to a.) ensure an accurate ordering and receiving of narcotic medications on the required Federal narcotic acquisition forms (DEA 222 forms) were completed with sufficient detail to enable accurate reconciliation for 6 of 6 forms provided; and b.) to accurately document the administration of controlled medication for 2 sampled residents (Resident #19 and Resident #216) identified upon inspection of 1 of 6 medication carts (1 [NAME] right hall cart). The evidence was as follows: 1. On 4/17/23 at 1:37 PM, the surveyor reviewed the facility provided DEA 222 forms which revealed on six of the six provided forms Part 5, had not been completed upon receipt of the medications from the Provider Pharmacy as instructed on the reverse of the ordering form. The forms were as follows: [...]

Inspectors wroteBased on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed a.) to ensure residents on transmission-based precautions (TBP) were treated in a dignified and respectful manner for their toileting needs and b.) ensuring the privacy curtain was closed during personal care. This deficient practice was identified for 2 of 35 residents (Residents #19 and #213) reviewed for dignity, and was evidenced by the following: 1. On 4/14/23 at 9:30 AM, during the initial tour of the facility, the surveyor observed cautionary signage and a personal protective equipment (PPE; clothing or equipment worn to protect the body from harm or infection) bin outside of Resident #19's room. [...]

Inspectors wroteBased on observation, interviews, and review of pertinent facility documents, it was determined that the facility failed to thoroughly investigate an allegation of abuse for 1 of 3 residents (Resident #152) reviewed for abuse. This deficient practice was evidenced by the following: On 4/3/23 at 11:18 AM, the surveyor observed Resident #152 laying on the bed requesting assistance from the nursing staff. On 4/12/23 at 10:20 AM, the surveyor was informed by Resident#152 of a situation involving a Certified Nursing Assistant (CNA). With Resident #152's permission, this conversation was held in the presence of their roommate (Resident #113). Resident #152 advised that the CNA grabbed my arm [ .] shook me [ .] I was crying. Resident #152 further stated that the CNA pulled on my arm [to cover me up] because I had a rash from dialysis. [...]

Inspectors wroteNJ Complaint #157789 Based on observations, interviews, and review of pertinent facility documents, it was determined that the facility failed to a.) implement care plan interventions of a silent bed alarm for a resident with a history of falls; and b.) develop and implement a care plan for a resident with limited range of motion which included daily right hand splints and a bilateral knee pillow. This deficient practice was identified for 2 of 35 residents (Resident #15 and #152) reviewed for comprehensive care plans and the evidence was as follows: 1. On 4/6/23 at 9:37 AM, the surveyor observed Resident #15 sitting in their wheelchair in their room asleep. The resident was wearing non-skid socks. The surveyor reviewed the medical record for Resident #15. [...]

Inspectors wroteBased on observations, interviews, review of pertinent facility documents, it was determined that the facility failed to ensure that residents who required extensive assistance from staff with activities of daily living (ADL) were provided care consistent with their needs and preferences. This deficient practice was identified for 2 of 4 residents (Resident #223 and Resident #285) reviewed for activities of daily living, and was evidenced by the following: 1. On 4/4/23 at 10:10 AM, during the initial tour of the facility, the surveyor observed Resident #223 lying in bed awake. The resident stated that they had left sided weakness related to a cerebrovascular accident (CVA; a loss of blood flow to part of the brain, which damages brain tissue). Resident #223 held up his/her left hand and demonstrated an impaired ability to fully open and close their left hand. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to ensure resident's weights obtained were accurate after significant weight changes. This deficient practice was identified for 1 of 4 residents (Resident #47) reviewed for nutrition and the evidence was as follows: On 4/3/23 at 11:20 AM, the surveyor observed Resident #47 sitting in wheelchair in the unit's dayroom. Resident #47 was petite and dressed in well-fitted clothes. On 4/6/23 9:45 AM, the surveyor observed Resident #47 sitting at table in dayroom eating their breakfast independently. The resident consumed approximately 75% of their meal. The surveyor reviewed the medical record for Resident #47. [...]

Inspectors wroteBased on observation, interview, and review of pertinent facility documents, it was determined that the facility failed to properly label and date medication in accordance with manufacturer recommendations. This deficient practice was observed in 1 of 3 medication storage rooms (1 West) inspected and was evidenced by the following: On 4/17/23 at 12:07 PM, the surveyor in the presence of the Licensed Practical Nurse (LPN) inspected the 1 [NAME] medication room refrigerator. The surveyor observed an opened and undated bottle of lorazepam 2 milligrams per 1 milliliter (mg/ml) concentrated oral solution in active inventory. The prescription label as well as the product label instructed Discard opened bottle after 90 days. The LPN acknowledged that neither the medication bottle nor the medication box had been dated when opened or when to discard and should have been. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined that the facility failed to a.) supervise the administration of one medication and b.) follow their policy for self-medication administration for 1 of 3 residents (Resident # 77) reviewed for oxygen, c.) follow fluid restriction instructions in accordance with the physician's order, professional standards of care and the care plan for 1 of 5 residents (Resident #242) reviewed for unnecessary medications, and d.) verify and accurately document the presence of a physician ordered pressure relieving device to the bed for 1 of 3 residents (Resident #242) reviewed for pressure ulcer/injury. This deficient practice 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 facility documentation, it was determined that the facility failed to a.) ensure that staff wore Personal Protective Equipment (PPE) properly when caring for long term care residents, this was noted for 1 staff member on 1 of 6 units (2 West); and b.) ensure the urinary catheter drainage bag (drainage bag) was stored in an appropriate manner to prevent the spread of infection for Resident #20, 1 of 3 resident's reviewed for the use of an indwelling urinary catheter. This deficient practice was evidenced by the following: 1. During the Entrance Conference with the facility on 04/13/21 at 9:50 AM, the Director of Nursing (DON) stated that the required PPE used on all units was an N95 face mask and face shield or goggles. [...]

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to ensure that the Minimum Data Set (MDS) Quarterly assessment was completed accurately. This was observed for 1 of 38 residents observed for MDS accuracy. This deficient practice was evidenced by the following: According to the admission Record, Resident #20 was admitted to the facility with medical diagnoses that included left sided Hemiplegia (paralysis on one side of the body) and Hemiparesis (weakness of one side of the body) following a stroke. Review of the Quarterly MDS, an assessment tool, dated 04/14/21, revealed Resident #20 was cognitively intact, needed extensive assistance from staff for Activities of Daily Living (ADLs) (transfers, dressing, toileting, personal hygiene and bathing). The 04/14/21 Quarterly MDS did not reflect an impairment to the upper or lower extremities. [...]