Inspection Reports for Elmwood Hills Healthcare Center Llc
425 Woodbury-Turnersville Road, NJ, 08012
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Notice
Deficiencies: 0
Nov 19, 2025
Visit Reason
This document serves to inform covered components and the public about the privacy practices related to medical information handled by NJDHSS, including how information may be used, disclosed, and the rights of individuals.
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 legal duties of NJDHSS to protect privacy.
Report Facts
Effective date: 2011
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Devon L. Graf | Director, Office of Legal and Regulatory Compliance | Listed as NJDHSS Privacy Officer contact for questions about the notice |
Inspection Report
Routine
Census: 290
Capacity: 290
Deficiencies: 7
May 9, 2025
Visit Reason
A Recertification Survey was conducted from 4/30/25 to 5/9/25 to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Findings
Deficiencies were cited related to comprehensive assessments, professional standards, ADL care, staffing, life safety code violations, medication administration, and infection control. Corrective actions were planned and monitored with compliance dates mostly set for 6/22/25.
Deficiencies (7)
| Description |
|---|
| Facility failed to complete a discharge Minimum Data Set (MDS) for Resident #275 within required timeframe. |
| Facility failed to meet professional standards in comprehensive care plans for Residents #104 and #196. |
| Facility failed to provide timely ADL care to Resident #247. |
| Facility failed to maintain minimum direct care staff-to-resident ratios as mandated by the state of New Jersey. |
| Life Safety Code violations including failure to provide required fire sprinkler coverage, exit signage, exit door hardware, and smoke barrier doors. |
| Facility failed to ensure medication administration was consistent with physician orders for multiple residents. |
| Facility failed to ensure proper infection control and immunization practices. |
Report Facts
Census: 290
Total Capacity: 290
Deficiency Count: 43
Staffing Hours: 720
Required Staffing Hours: 768.5
Staffing Hours Deficit: 48.5
Compliance Date: Jun 22, 2025
Inspection Report
Complaint Investigation
Census: 285
Deficiencies: 0
Apr 23, 2025
Visit Reason
The inspection visit was conducted based on complaints NJ165069 and NJ185528.
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.
Complaint Details
Complaint numbers NJ165069 and NJ185528 were investigated and the facility was found to be in substantial compliance.
Report Facts
Sample size: 4
Inspection Report
Complaint Investigation
Census: 276
Deficiencies: 1
Dec 28, 2024
Visit Reason
A complaint survey was conducted on behalf of the New Jersey Department of Health covering multiple complaint numbers. The survey was conducted to investigate staffing ratio deficiencies and compliance with state regulations.
Findings
The facility was found to be deficient in meeting minimum staffing ratios for Certified Nurse Aides (CNAs) during 10 weeks of day shifts reviewed, with multiple days showing CNA staffing below the required minimum. The facility was found to be in substantial compliance overall but failed to meet staffing requirements as per New Jersey statutes.
Complaint Details
The complaint survey was based on multiple complaint numbers (NJ00164407, NJ00165930, NJ00166250, NJ00168595, NJ00169030, NJ00175092, NJ00176126, NJ00177489, NJ00179988, and NJ00179310). The facility was found to be deficient in CNA staffing on numerous days across several weeks, affecting all residents. The facility was not in compliance with New Jersey Administrative Code Chapter 8:39 standards for licensure of long term care facilities.
Deficiencies (1)
| Description |
|---|
| Failed to ensure staffing ratios were met for 10 weeks of day shifts reviewed, including CNA staffing deficiencies on multiple days. |
Report Facts
Survey Census: 276
Sample Size: 12
Staffing Deficiencies: 10
Deficient CNA staffing days: 12
Inspection Report
Complaint Investigation
Census: 276
Deficiencies: 1
Sep 12, 2024
Visit Reason
The inspection was conducted in response to complaint NJ174159 to investigate staffing ratio deficiencies at Elmwood Hills Healthcare Center LLC.
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 10 of 14 day shifts and 1 of 14 overnight shifts reviewed. The deficiency had the potential to affect all residents.
Complaint Details
Complaint #: NJ174159. The facility was substantiated to have failed to meet staffing ratios as required by law, based on interviews and document review on 09/16/2024.
Deficiencies (1)
| Description |
|---|
| Failure to ensure staffing ratios were met for 10 of 14 day shifts and 1 of 14 overnight shifts, violating mandatory access to care requirements. |
Report Facts
Census: 276
Sample size: 3
Staffing deficiency days: 10
Staffing deficiency nights: 1
Date of compliance: Oct 10, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Named as responsible for meeting daily with staffing coordinator to review staff sufficiency and conducting daily CNA staffing audits. | |
| Staffing Coordinator | Named as responsible for sending daily staffing numbers to Administrator and Director of Nursing. | |
| Administrator | Receives staffing reports and reports CNA staffing audit findings to Quality Assessment and Assurance Committee. |
Inspection Report
Complaint Investigation
Census: 279
Deficiencies: 1
Jul 16, 2024
Visit Reason
The inspection was conducted based on complaint NJ00175495 to investigate compliance with staffing ratios and other regulatory requirements at Elmwood Hills Healthcare Center.
Findings
The facility was found not in compliance with New Jersey Administrative Code staffing requirements, failing to meet minimum staff-to-resident ratios on 8 of 28 day shifts, potentially affecting all residents. A plan of correction was submitted and corrective actions were implemented.
Complaint Details
Complaint NJ00175495 was investigated and the facility was found not in compliance with staffing requirements. The deficiency was substantiated with evidence of insufficient Certified Nurse Aide staffing on multiple days.
Deficiencies (1)
| Description |
|---|
| Failed to ensure staffing ratios were met to maintain the required minimum staff-to-resident ratios as mandated by the state of New Jersey for 8 of 28 day shifts. |
Report Facts
Census: 279
Sample Size: 4
Deficient Day Shifts: 8
CNA Staffing Required: 34
CNA Staffing Actual: 26
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Named in corrective action plan as meeting daily with staffing coordinator to review staff sufficiency. | |
| Staffing Coordinator | Sends daily emails with staffing numbers to Administrator and Director of Nursing. |
Inspection Report
Abbreviated Survey
Census: 285
Deficiencies: 0
Aug 16, 2023
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 CMS and CDC recommended practices to prepare for COVID-19.
Report Facts
Sample Size: 9
Inspection Report
Annual Inspection
Census: 286
Deficiencies: 12
Apr 19, 2023
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities.
Findings
The facility was found not in compliance with multiple regulatory requirements including staffing ratios, resident rights and dignity, abuse reporting and investigation, care planning, medication management, food safety, infection control, and quality of care. Deficiencies were cited in areas such as minimum staffing, resident dignity during care, failure to report abuse and injuries, incomplete care plans, medication documentation errors, food temperature and storage issues, and infection prevention practices.
Complaint Details
NJ Complaint #157789; 158780; 155891; 157938; 159807. Multiple complaints related to staffing shortages, resident dignity violations, failure to report abuse and injuries, inadequate care planning, medication errors, food safety concerns, and infection control breaches.
Severity Breakdown
S 560: 1
F 550: 1
F 609: 1
F 610: 1
F 656: 1
F 677: 1
F 692: 1
F 693: 1
F 755: 1
F 761: 1
F 804: 1
F 880: 1
Deficiencies (12)
| Description | Severity |
|---|---|
| Failed to maintain required minimum direct care staff to resident ratios as mandated by the State of New Jersey. | S 560 |
| Failed to ensure residents on transmission-based precautions were treated with dignity and privacy, including toileting needs and privacy curtain use during care. | F 550 |
| Failed to report alleged violations of abuse, neglect, and injuries of unknown origin to the State Department of Health within required timeframes. | F 609 |
| Failed to thoroughly investigate allegations of abuse and properly document grievance investigations. | F 610 |
| Failed to implement and update comprehensive care plans including interventions for residents at risk for falls and those requiring specialized care. | F 656 |
| Failed to provide care consistent with resident needs and preferences for activities of daily living, including personal hygiene and nail care. | F 677 |
| Failed to ensure accurate resident weights after significant weight changes and proper documentation of weights. | F 692 |
| Failed to ensure appropriate management of enteral nutrition including proper labeling, dating, and administration of feeding sets. | F 693 |
| Failed to ensure accurate ordering and receiving of narcotic medications and accurate documentation of administration on controlled medication inventory sheets. | F 755 |
| Failed to properly label, date, and store medications in accordance with manufacturer recommendations. | F 761 |
| Failed to ensure food was served at safe and appetizing temperatures and failed to maintain sanitary food preparation and storage practices including dish machine function and cleaning. | F 804 |
| Failed to maintain an infection prevention and control program including proper use of personal protective equipment, hand hygiene, disposal of contaminated materials, and cleaning of resident rooms and equipment. | F 880 |
Report Facts
Staffing ratios: 27
Resident census: 286
Deficiency counts: 12
Weight changes: 5
Medication count discrepancy: 1
Medication count discrepancy: 1
Food temperature: 37
Food temperature: 45
Food temperature: 47
Food temperature: 125
Food temperature: 132
Food temperature: 58
Food temperature: 178
Food temperature: 80
Food temperature: 90
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in medication administration and narcotic inventory discrepancy. |
| LPN #2 | Licensed Practical Nurse | Named in medication administration and narcotic inventory discrepancy. |
| CNA #1 | Certified Nursing Assistant | Named in infection control and abuse investigation deficiencies. |
| HK #1 | Housekeeper | Named in infection control deficiencies. |
| HK #2 | Housekeeper | Named in infection control deficiencies. |
| HK #3 | Housekeeper | Named in infection control deficiencies. |
| OT | Occupational Therapist | Named in infection control deficiencies. |
| DON | Director of Nursing | Named in multiple findings and interviews. |
| FSD | Food Service Director | Named in food safety and temperature monitoring deficiencies. |
| CM | Chef Manager | Named in food safety and temperature monitoring deficiencies. |
| IP | Infection Preventionist | Named in infection control deficiencies and staff education. |
| DON #1 | Director of Nursing | Named in narcotic medication ordering and documentation deficiencies. |
Inspection Report
Life Safety
Census: 286
Deficiencies: 0
Apr 19, 2023
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the 2012 edition of the National Fire Protection Association (NFPA) 101 Life Safety Code for existing health care occupancy.
Findings
The facility was found to be in compliance with all applicable Life Safety Code requirements and emergency preparedness regulations during the survey conducted on 04/12/23 and 04/13/23.
Report Facts
Smoke zones: 10
Standby generator capacity (KW): 1500
Standby generator underload test percentage: 33
Inspection Report
Complaint Investigation
Census: 282
Deficiencies: 1
Jun 29, 2022
Visit Reason
The inspection was conducted as a complaint survey based on multiple complaints (NJ149361, NJ150335, NJ152254, NJ152699, and NJ154513) to determine compliance with 42 CFR Part 483, Subpart B, for Long Term Care Facilities.
Findings
The facility failed to ensure quality of care by inaccurately transcribing and administering a physician's medication order for one resident, resulting in the resident receiving a medication routinely instead of as needed. The error was discovered by the physician, the medication was discontinued, and no harm was reported. The nurse responsible received education and monitoring, and systemic changes were implemented to prevent recurrence.
Complaint Details
The survey was complaint-driven based on five complaint numbers. The facility was found not in compliance with quality of care requirements due to the medication transcription error affecting Resident #1.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure physician's medication orders were accurately transcribed and followed for one resident, leading to incorrect routine administration of a PRN medication. | SS=D |
Report Facts
Census: 282
Sample Size: 13
Medication doses administered: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Nurse responsible for the medication transcription error and subsequent education and monitoring |
| Director of Nursing | Director of Nursing | Provided information about the transcription error and corrective actions |
| Administrator | Administrator | Provided information about the transcription error and facility expectations |
| Physician (MD) #1 | Physician | Discovered the medication transcription error |
| Physician Assistant (PA) #1 | Physician Assistant | Covered for primary physician and reported on the medication transcription error |
Inspection Report
Routine
Census: 278
Deficiencies: 0
Dec 21, 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 related to COVID-19.
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: 5
Inspection Report
Complaint Investigation
Census: 259
Deficiencies: 0
Aug 9, 2021
Visit Reason
The inspection was conducted based on a complaint visit to assess compliance with 42 CFR Part 483, Subpart B for long term care facilities.
Findings
The facility was found to be in compliance with the regulatory requirements during this complaint investigation.
Complaint Details
The complaint investigation concluded that the facility is in compliance with the requirements; no deficiencies were cited.
Report Facts
Sample Size: 3
Inspection Report
Complaint Investigation
Census: 259
Deficiencies: 0
Jul 23, 2021
Visit Reason
The inspection was conducted as a complaint survey based on complaints NJ146023 and NJ145286.
Findings
The facility was found to be in compliance with the requirements of 42 CFR Part 483, Subpart B, for Long Term Care Facilities based on this complaint survey.
Complaint Details
Complaint #: NJ146023 and NJ145286. The facility was found compliant based on this complaint survey.
Report Facts
Sample Size: 12
Inspection Report
Annual Inspection
Census: 246
Deficiencies: 4
Apr 22, 2021
Visit Reason
A Recertification Survey was conducted to determine compliance with 42 CFR Part 483, Requirements for Long Term Care Facilities, including a COVID-19 Focused Infection Control Survey.
Findings
Deficiencies were cited related to accuracy of assessments, services meeting professional standards including medication administration and care plan compliance, infection prevention and control practices, and proper use and storage of equipment such as air mattresses and personal protective equipment (PPE). The facility was found compliant with COVID-19 infection control regulations but had issues with PPE use and equipment management.
Severity Breakdown
SS=B: 1
SS=E: 1
SS=D: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to ensure the Minimum Data Set (MDS) Quarterly assessment was completed accurately for one resident. | SS=B |
| Failure to supervise medication administration, follow self-medication policy, and follow physician's orders for medications and devices for residents. | SS=E |
| Failure to ensure proper placement and function verification of a physician-ordered air mattress for pressure injury prevention. | — |
| Failure to ensure staff wore Personal Protective Equipment (PPE) properly and to store equipment to prevent infection spread. | SS=D |
Report Facts
Census: 246
Sample size: 44
Deficiencies cited: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding MDS accuracy and infection control | |
| Licensed Practical Nurse Unit Manager | Interviewed regarding resident care and medication administration | |
| Registered Nurse | Observed not wearing face shield properly during medication administration | |
| Infection Preventionist | Provided information on PPE orientation and infection control policies | |
| Certified Nursing Assistant | Interviewed regarding equipment placement and resident care |
Inspection Report
Life Safety
Deficiencies: 0
Apr 22, 2021
Visit Reason
The inspection was conducted to assess compliance with the Life Safety Code 101:2012 and emergency preparedness requirements for long term care facilities.
Findings
The facility was found to be in substantial compliance with emergency preparedness requirements and in compliance with the minimum Life Safety Code requirements as surveyed using CMS-2786R.
Inspection Report
Complaint Investigation
Census: 257
Deficiencies: 0
Apr 7, 2021
Visit Reason
The inspection was conducted as a complaint investigation based on multiple complaint numbers NJ135566, NJ135860, NJ141733, NJ141882, NJ142390, NJ143796, and NJ144316.
Findings
The facility was found to be in compliance with the requirements of 42 CFR Part 483, Subpart B, for long term care facilities based on this complaint visit.
Complaint Details
Complaint numbers NJ135566, NJ135860, NJ141733, NJ141882, NJ142390, NJ143796, NJ144316 were investigated and the facility was found to be in compliance.
Report Facts
Sample Size: 6
Inspection Report
Routine
Census: 262
Deficiencies: 0
Jan 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.
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: 5
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