Inspection Reports for
Elmwood Hills Healthcare Center Llc

Complaint #2629258 involved Resident #2 who eloped from the secured unit and exited the building on 2025-09-28. The complaint was substantiated with findings that staff failed to recognize the resident and allowed exit through a locked door using an employee badge. The security guard did not intervene to stop the resident initially. The facility was notified of the Immediate Jeopardy on 2025-10-10 and submitted a Removal Plan on 2025-10-15.

The facility failed to prevent Resident #2 from eloping out of the secured unit and exiting the building due to staff not recognizing the resident and improperly allowing exit through a locked door. This resulted in an Immediate Jeopardy situation that was removed after the facility implemented a corrective action plan including 1:1 monitoring, staff re-education, and audits to ensure compliance with the Elopement Policy.

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.

Complaint #NJ176228 related to urinary catheter care and documentation; Complaint #NJ165862 and #NJ184181 related to incontinence care.

The facility failed to follow physician orders to apply urinary catheter stabilization devices, accurately document urinary catheter use and output, and provide timely incontinence care to dependent residents. These deficiencies were identified for multiple residents and confirmed through observations, interviews, and record reviews.

Complaint numbers NJ176228, NJ165862, NJ184181, and NJ00176228 were investigated related to urinary catheter care, incontinence care, pain medication administration, hearing aid management, skin assessments, and immunizations.

The facility was found deficient in multiple areas including failure to complete discharge MDS timely, failure to apply urinary catheter stabilization devices and monitor urinary output as ordered, failure to provide timely incontinence care, failure to provide range of motion care, failure to administer oxygen according to physician orders, failure to administer pain medication appropriately, failure to maintain and document hearing aid use, failure to accurately document weekly skin assessments, and failure to administer pneumococcal vaccine upon admission as required.

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.

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 #: 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.

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 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.

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.

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.

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.

The complaint investigation involved three residents (#15, #152, and #440) with allegations of failure to report injuries and abuse to the NJDOH. Resident #440 reported inappropriate language by a CNA. Resident #15 had an injury of unknown origin that was not reported. Resident #152 alleged mistreatment by a CNA. The facility's investigations concluded some allegations were unfounded, and none were reported to NJDOH within required timeframes.

The facility failed to report three incidents to the New Jersey Department of Health involving injury of unknown origin, staff to resident abuse, and mistreatment for three residents. Additionally, the facility failed to ensure timely and appropriate care for a resident with an indwelling pleural chest catheter who experienced respiratory distress and delayed chest x-ray and hospitalization.

The facility was found deficient in multiple areas including resident dignity and privacy, abuse investigation and reporting, care plan implementation, medication management, nutrition and weight monitoring, feeding tube management, pharmaceutical services, food safety and sanitation, and infection control practices.

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.

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.

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.

The facility was found deficient in accurately completing Minimum Data Set (MDS) assessments, supervising medication administration and self-medication policies, adhering to physician-ordered fluid restrictions, verifying and documenting pressure-relieving devices, ensuring proper use of Personal Protective Equipment (PPE) by staff, and maintaining urinary catheter drainage bags properly.