Elmwood Hills Healthcare Center LLC

In the surveyor’s words

From the most serious findings on record at Elmwood Hills Healthcare Center LLC, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Oct 16, 2025

  Complaint #: 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. […]

• Actual harm, isolatedF684Apr 19, 2023

  NJ 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. […]

• No harm, potential for more than minimal, widespreadF804Apr 19, 2023

  Based 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. […]

• No harm, potential for more than minimal, widespreadF812Apr 19, 2023

  Based 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… […]

• No harm, potential for more than minimal, widespreadF880Apr 19, 2023

  Based 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. […]