Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Elmwood Hills Healthcare Center Llc during CMS and state inspections, most recent first.
A resident with cognitive impairment and a history of exit-seeking behaviors eloped from a secured unit after an LPN and CNA, unfamiliar with the resident, allowed them to exit by swiping open a locked door without checking posted identification photos. The resident, wearing an ID band and carrying bags, was mistaken for a visitor by both staff and the security guard, who did not intervene as the resident exited the building. Staff failed to follow established protocols for identifying and supervising residents at risk for elopement.
The facility did not consistently meet New Jersey's required CNA-to-resident ratios on numerous day and some overnight shifts, as confirmed by staffing records and staff interviews. Despite awareness of the mandated ratios and a policy reflecting these standards, the facility's staffing levels repeatedly fell short of requirements during several reviewed periods.
The facility did not provide the minimum required nursing staffing hours on two days, with actual hours falling short of the calculated requirement based on resident count and acuity, despite having a contingency staffing plan in place.
The facility consistently failed to meet New Jersey's mandatory staffing ratios for CNAs, affecting multiple day shifts over several weeks. This deficiency was observed across various periods, with significant shortfalls in CNA staffing, indicating a pattern of non-compliance with state regulations.
Elopement Due to Inadequate Supervision and Identification Failures
Penalty
Summary
A cognitively impaired resident with a history of exit-seeking behaviors was able to elope from a secured unit due to inadequate supervision and failure to follow established identification protocols. The resident, who had diagnoses including dementia, depression, anxiety disorder, and altered mental status, was assessed as needing supervision for decision-making regarding wandering and elopement risk. Despite documented behaviors such as repeatedly asking to go home and inquiring about how to leave the facility, staff did not consistently reassess or update interventions after these behaviors were observed and reported. On the day of the incident, the resident was able to exit the secured unit after an LPN, unfamiliar with the resident and not given a report, asked a CNA to use her badge to open the locked door, mistakenly believing the resident was a visitor. Both staff members failed to check the posted pictures of residents at risk for elopement, which were intended to help staff identify and prevent such incidents. The resident, wearing an ID band, proceeded to the first-floor lobby and exited the building through the front door while carrying bags of clothing. The security guard at the front desk also failed to recognize the resident as a patient and did not intervene, only responding after being alerted by a visitor. Interviews and documentation revealed that staff on the unit, including the LPN and CNA involved, did not recognize the resident or utilize the available identification tools, such as the posted photographs and ID bands. Communication lapses were evident, as the LPN was not educated about the identification system and had not received a report on the resident. The facility's policy required staff to identify and intervene with residents at risk for elopement, but these procedures were not followed, resulting in the resident leaving the building unsupervised.
Removal Plan
- Resident was assessed post incident by Nursing Supervisor, placed on 1:1 monitoring for safety.
- A call was placed to the primary physician by the nursing supervisor.
- The nursing supervisor updated Resident's care plan.
- All staff were re-educated on the Elopement Policy.
- A new system was implemented that all visitors must sign out upon leaving the building.
- Security staff and receptionist staff were educated on the Elopement Policy and the new process for visitors signing out.
- All nursing staff were re-educated on identifying elopement behaviors and initiating and completing a new Elopement Assessment, updating the resident's care plan and placing the resident picture at the entrance of the unit, receptionist desk, and security console.
- An audit was completed on all residents who are an elopement risk to ensure they have an appropriate Care Plan, Elopement Assessment and resident picture at receptionist binder and security console.
- An audit was completed on all new admissions by the Infection Preventionist nurse and Nursing Supervisor to assure that residents identified at risk of elopement had an elopement care plan in place, ID band and picture on the wall of exit door and front reception desk and security desk.
- An audit was completed by the Nursing Supervisor on resident ID bands to ensure all residents had an ID band in place and that all resident pictures were present in Point Click Care as a form of identification. Refusal of pictures and/or ID band were indicated on the resident's care plan.
- The DON, ADON and ICP re-reviewed the Elopement Policy.
- The Nursing Supervisor and the ADONs completed the re-education on the Elopement Policy for staff.
- All unit doors continue to remain locked and continue to require a swipe ID card to get off all the Nursing Units.
Failure to Maintain Minimum CNA Staffing Ratios
Penalty
Summary
The facility failed to maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey. This deficiency was identified through observation, interviews, and review of facility documentation, and was evidenced by multiple instances where the number of Certified Nurse Aides (CNAs) scheduled for the day shift was below the minimum required for the census. The deficiency was found on 43 of 49 day shifts and 4 of 49 overnight shifts reviewed across several complaint periods, with specific examples provided for each period showing the number of CNAs present versus the number required by law. Interviews with the Staffing Coordinator, DON, and LNHA confirmed their awareness of the state-mandated ratios (1:8 for day shift, 1:10 for evening, and 1:14 for night), but also revealed that the facility did not always meet these requirements. The Staffing Coordinator stated that when there was a shortfall, other staff members who were also CNAs, such as the Staffing Coordinator, Unit Clerks, or Recruiter, would provide resident care. Despite these efforts, the documented staffing levels on numerous shifts did not meet the minimum ratios. A review of the facility's own Nursing Staffing Policy, revised in January 2025, reiterated the commitment to adhere to state staffing standards and outlined the required CNA ratios. However, the documented staffing schedules for multiple weeks showed consistent shortfalls in CNA coverage, particularly on the day shift, and occasional deficiencies in total staff on overnight shifts. No specific residents or patient conditions were mentioned in relation to the deficiency.
Plan Of Correction
I. Corrective Action Accomplished for Resident(s) Affected: Director of Nursing/Designee meets daily and before weekends with a staffing coordinator to review staff sufficiency to ensure minimum staffing hours requirement is met along with extra hours needed to meet special services need of our residents as required at N.J.A.C 8:39-25.1. Staffing coordinators will send daily emails with the staffing number to the Administrator and Director of Nursing and ADONs and Nursing Supervisor. II. Residents identified having the potential to be affected and corrective action taken: All residents residing in the facility had the potential to be affected. A random sample of twenty alert and oriented residents were interviewed regarding staff response times to requests for assistance with concerns reported to the Director of Nursing for rectification. III. Measures to be put in place to ensure the deficient practice will not recur: The Call Out Policy was reviewed by the facility administration and staff have been reeducated by the Facility Educator on the policy. Referral and Sign-on Bonuses are offered for both Licensed and Certified Nursing Staff. The Retention and Recruitment Coordinator and Nurse Educator meet at area Nursing and CNA Schools and host job fairs. Interviews are done on the spot. Staffing needs for the day are assessed daily and evaluated if the Nursing Management (Unit Managers, ADON, and Facility Educator) needs to assist with resident care. Staff recognition is done monthly, a monthly incentive is offered for staff that do not call out. Elmwood Hills established a recruitment and retention committee. Elmwood Hills hired a recruitment and retention employee. Elmwood Hills does weekly Orientation. Elmwood Hills uses multiple employment search engines and multiple social media platforms. Elmwood Hills does recruitment events at area CNA schools; interviews are done on the spot. Elmwood Hills continues to offer flexible schedules to staff. Alert and Oriented residents will be interviewed regarding the timeliness of staff response when requesting help as part of their Quarterly care conference meetings. This date will be reported to Social Services quarterly to the QA Committee for the next two meetings, which will evaluate that the deficiency remains corrected and in compliance with regulatory requirements. IV. Corrective Action will be monitored to ensure the deficient practice will not recur: The Director of Nursing (DON)/Designee will conduct daily Certified Nursing Assistant (CNA) staffing schedule audits for the next six months. The DON/designee will report audit findings to the Administrator for analysis, tracking, and trending. The Administrator will report the findings of the Certified Nursing Assistant staffing audits to the Quality Assessment and Assurance (QAA) Committee for the next two quarters. The QAA committee will determine the need for any additional monitoring of Certified Nursing Assistant staffing after the 2nd quarterly meeting. V. Date of Compliance: 6/22/25
Failure to Meet Mandatory Nurse Staffing Requirements
Penalty
Summary
The facility failed to meet the mandatory nurse staffing requirements as outlined in N.J.A.C. 8:39-25.2(b)(1)&(2) for 2 out of 14 days during the review period. Specifically, on two separate days, the actual nursing staffing hours fell short of the required minimum hours calculated based on the total number of residents and the acuity of care needed, including services such as wound care, tube feedings, oxygen therapy, tracheostomy, intravenous therapy, respirator use, and advanced neuromuscular/orthopedic care. On one day, there was a deficit of 48.5 hours, and on another, a deficit of 15.75 hours compared to the required staffing levels. The deficiency was identified through a review of the Nursing Staffing Reports for the two weeks prior to the survey, which was conducted in response to specific complaints. The facility's contingency staffing plan, dated 8/1/24, was also reviewed and included provisions to ensure sufficient qualified staff to meet residents' needs based on assessments and care plans. However, despite this plan, the facility did not provide the minimum required nursing hours on the identified days.
Plan Of Correction
I. Corrective Action accomplished for Resident(s) affected: Director of Nursing/Designee meets daily and before weekends with a staffing coordinator to review staff sufficiency to ensure the minimum staffing hours requirement is met along with the extra hours needed to meet the special services needs of our residents as required at N.J.A.C 8:39-25.1. Staffing coordinators will send daily emails with the staffing number to the Administrator and Director of Nursing and ADONs and Nursing Supervisor. II. Residents identified having the potential to be affected and corrective action taken: All residents residing in the facility had the potential to be affected. A random sample of twenty alert and oriented residents were interviewed regarding staff response times to requests for assistance with concerns reported to the Director of Nursing for rectification. III. Measures to be put in place to ensure the deficient practice will not recur: The Call Out Policy was reviewed by the facility administration and staff have been reeducated by the Facility Educator on the policy. Referral and Sign-on Bonuses are offered for both Licensed and Certified Nursing Staff. The Retention and Recruitment Coordinator and Nurse Educator meet at area Nursing and CNA Schools and host job fairs. Interviews are done on the spot. Staffing needs for the day are assessed daily and evaluated if the Nursing Management (Unit Managers, ADON, and Facility Educator) needs to assist with resident care. Staff recognition is done monthly, a monthly incentive is offered for staff that do not call out. Elmwood Hills established a recruitment and retention committee. Elmwood Hills hired a recruitment and retention employee. Elmwood Hills does weekly Orientation. Elmwood Hills uses multiple employment search engines and multiple social media platforms. Elmwood Hills does recruitment events at area CNA schools; interviews are done on the spot. Elmwood Hills continues to offer flexible schedules to staff. Alert and Oriented residents will be interviewed regarding the timeliness of staff response when requesting help as part of their Quarterly care conference meetings. This date will be reported to Social Services quarterly to the QA Committee for the next two meetings, which will evaluate that the deficiency remains corrected and in compliance with regulatory requirements. IV. Corrective Action will be monitored to ensure the deficient practice will not recur: The Director of Nursing (DON)/Designee will conduct daily Certified Nursing (CNA) staffing schedule audits for the next six months. The DON/designee will report audit findings to the Administrator for analysis, tracking, and trending. The Administrator will report on the findings of the Certified Nursing Assistant staffing audits to the Quality Assessment and Assurance (QAA) Committee for the next two quarters. The QAA committee will determine the need for any additional monitoring of Certified Nursing Assistant staffing after the 2nd quarterly meeting. V. Date of Compliance: 6/22/25
Facility Fails to Meet Mandatory Staffing Ratios
Penalty
Summary
The facility failed to meet the mandatory staffing ratios as required by New Jersey law, specifically N.J.S.A. 30:13-18, which mandates minimum staffing levels in nursing homes. The deficiency was identified during a review of staffing records over several weeks, revealing that the facility did not have the required number of Certified Nurse Aides (CNAs) on multiple day shifts. This failure to comply with staffing requirements had the potential to affect all residents in the facility. The report details specific instances where the facility was understaffed. For example, during the week of May 21, 2023, to May 27, 2023, the facility was short of CNAs on two day shifts. Similar deficiencies were noted in subsequent weeks, including significant shortfalls in CNA staffing during the weeks of July 23, 2023, to August 5, 2023, and October 22, 2023, to October 28, 2023. These staffing shortages were consistent across various weeks, indicating a pattern of non-compliance with the mandated staffing ratios. The report highlights that the facility's staffing deficiencies were not limited to day shifts but also included evening and overnight shifts. For instance, during the week of November 3, 2024, to November 9, 2024, the facility was deficient in both CNA staffing and total staff on several shifts. The consistent failure to meet staffing requirements across multiple weeks and shifts underscores a systemic issue within the facility's staffing practices.
Plan Of Correction
I. Corrective Action accomplished for Resident(s) affected: Director of Nursing/Designee meets daily and before weekends with staffing coordinator to review staff sufficiency. Staffing coordinators will send daily emails with the staffing number to the Administrator and Director of Nursing and ADON's and Nursing Supervisor. II. Residents identified having the Potential to be affected and corrective action taken: All residents residing in the facility had the potential to be affected. A random sample of Twenty alert and oriented residents were interviewed regarding staff response times to requests for assistance with concerns reported to the Director of Nursing for rectification. III. Measures to be put in place to ensure the deficient practice will not recur: The Call Out Policy was reviewed by the facility administration and staff have been reeducated by the Facility Educator on the policy. Referral and Sign-on Bonuses are offered for both Licensed and Certified Nursing Staff. The Retention and Recruitment Coordinator and Nurse Educator meet at area Nursing and CNA Schools and host job fairs. Interviews are done on the spot. Staffing needs for the day are assessed daily and evaluated if the Nursing Management (Unit Managers, ADON, and Facility Educator) needs to assist with resident care. Staff recognition is done monthly, a monthly incentive is offered for staff that do not call out. Elmwood Hills established a recruitment and retention committee. Elmwood Hills hired a recruitment and retention employee. Elmwood Hills does weekly Orientation. Elmwood Hills uses multiple employment search engines and multiple social media platforms. Elmwood Hills does recruitment events at area CNA schools; interviews are done on the spot at the area schools. In addition, two employees are on the Camden County College Advisory Committee and encourage new students and graduating students to apply at Elmwood Hills. Elmwood Hills continues to offer flexible schedules to staff. Alert and Oriented residents will be interviewed regarding the timeliness of staff response when requesting help as part of their Quarterly care conference meetings. This date will be reported to Social Services quarterly to the QA Committee for the next two meetings, which will evaluate that the deficiency remains corrected and in compliance with regulatory requirements. IV. Corrective Action will be monitored to ensure the deficient practice will not recur: The Director of Nursing (DON)/Designee will conduct daily Certified Nursing (CNA) staffing schedule audits for the next six months. The DON/designee will report audit findings to the Administrator for analysis, tracking and trending. The Administrator will report on the findings of the Certified Nursing Assistant staffing audits to the Quality Assessment and Assurance (QAA) Committee for the next two quarters. The QAA committee will determine the need for any additional monitoring of Certified Nursing Assistant staffing after the 2nd quarterly meeting. V. Date of Compliance: 1/17/25
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Blackwood
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Deptford Center For Rehabilitation And Healthcare | 3.1 mi | ★★★★★ | 13 | 0 |
| Advanced Subacute Rehabilitation Center At Sewell | 3.2 mi | ★★★★★ | 2 | 0 |
| The Center For Rehab & Nursing Washington Township | 3.7 mi | ★★★★★ | 18 | 1 |
| Laurel Manor Healthcare And Rehabilitation Center | 4.3 mi | ★★★★★ | 10 | 0 |
| Atlas Post Acute At Woodbury Country Club | 4.5 mi | ★★★★★ | 1 | 0 |
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