Staffing and Mask-Wearing Deficiencies
Summary
The facility failed to maintain the required minimum direct care staff-to-shift ratios as mandated by the state of New Jersey. This deficiency was observed over multiple periods, including specific weeks in October 2023, June to July 2024, and December 2024. During these times, the facility consistently had fewer Certified Nurse Aides (CNAs) than required for the day shifts, and there were also deficiencies in total staff numbers for evening and overnight shifts. Interviews with the Human Resources director and the Director of Nursing revealed attempts to meet staffing ratios through bonuses and agency staff, but these efforts were not always successful. Additionally, the facility did not ensure that employees with medical exemptions from the influenza vaccine wore surgical or procedural masks when in direct contact with patients and in common areas, as required by New Jersey law. The surveyor observed that two employees, a dietary employee and an activity employee, were not wearing masks despite having medical exemptions from the influenza vaccine. Interviews with these employees indicated a lack of awareness or enforcement of the mask-wearing requirement. The facility's policy on influenza vaccination did not address the use of masks for employees with medical exemptions. The Director of Nursing was unaware of the requirement for these employees to wear masks, which contributed to the deficiency. The facility's failure to comply with staffing ratios and mask-wearing requirements for exempt employees highlights significant lapses in adhering to state regulations designed to ensure resident safety and care quality.
Plan Of Correction
Element 1 It is the practice of the facility to ensure that the minimum direct care staff-to-shift ratios are in compliance with the mandate from the State of New Jersey. The deficiency is being corrected by offering bonuses and overtime to staff to cover openings/callouts in the schedule, offering openings/callouts to staffing agencies, utilizing job search engines (Apploi) to expand the view of job postings, and meeting with Certified Nursing Assistant schools to speak with newly graduating individuals. Additionally, all staff members who are Medically Exempt from receiving the Flu Vaccine were immediately informed they must wear a surgical mask while within the facility, and given masks to wear. Element 2 All residents are affected by this deficiency. Element 3 The deficiency is being corrected by offering bonuses and overtime, utilizing staffing agencies, utilizing job search engines (Apploi), and meeting with Certified Nursing Assistant schools to speak with newly graduating individuals. Additionally, a Staffing Audit is being conducted by the Staffing Coordinator to ensure the facility remains in compliance with S560. Staff were also educated that they must wear a mask while in the facility if they are Medically Exempt from receiving the Flu Vaccine; a Mask Audit is being conducted by the Infection Preventionist to ensure the facility remains in compliance. Element 4 To maintain and monitor ongoing compliance, the Staffing Audit is being monitored by the Administrator or designee once a week for two months, then once every other week for two months, and then once a month for two months. Additionally, the Mask Audit is being monitored by the Director of Nursing or designee once a week for two months, then once every other week for two months, and then once a month for two months. Identified issues will be corrected as they are discovered, results will be reported to the Administrator and will be reviewed at quarterly QAPI meetings for six months to the Quality Assurance Performance Improvement team for review and action as necessary.
Penalty
The facility did not meet the required CNA-to-resident staffing ratio for one day shift, providing only 10 CNAs for 87 residents when at least 11 were required. This deficiency was identified through staffing records and confirmed during an interview with the Staffing Coordinator, who stated she was aware of the staffing requirements.
The facility did not meet the required CNA-to-resident staffing ratios for 14 consecutive day shifts, consistently scheduling fewer CNAs than mandated by state law for the number of residents present. This deficiency was identified through review of staffing records and interviews, and had the potential to affect all residents.
The facility did not meet required CNA-to-resident staffing ratios on multiple day shifts over several weeks, with staffing levels consistently below state-mandated minimums for the number of residents present. This deficiency was identified through interviews and review of facility records, and had the potential to affect all residents.
The facility did not meet required CNA staffing ratios on multiple day shifts and was also deficient in total direct care staff on one evening shift, as mandated by New Jersey law. These deficiencies were identified through review of staffing records and interviews, with the shortfall in CNAs and direct care staff having the potential to affect all residents.
The facility did not meet New Jersey's required CNA-to-resident ratios on numerous day shifts, with staffing records showing multiple instances where fewer CNAs were scheduled than mandated for the census. The staffing coordinator acknowledged knowledge of the ratios and cited last-minute call outs as a reason for shortfalls, despite the facility's policy requiring sufficient staff to ensure resident safety and well-being.
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.
Failure to Meet 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 for one out of fourteen day shifts reviewed. Specifically, on one day shift, there were only 10 Certified Nurse Aides (CNAs) present for 87 residents, whereas the required minimum was 11 CNAs. This deficiency was identified through a review of the facility's "Nursing Staffing Report" for the specified weeks. During an interview, the Staffing Coordinator stated she was familiar with the CNA staffing ratios and believed the facility was able to meet them. The facility's staffing policy, reviewed in January 2025, indicated that staffing assignments were developed in accordance with resident needs and relevant regulations. However, the documentation and staffing records reviewed by the surveyor demonstrated that the facility did not meet the mandated CNA-to-resident ratio for at least one shift.
Plan Of Correction
Element #1 The staffing coordinator was in-serviced on 6/20/2025 by the Administrator and Nursing Director; education provided included the importance of meeting the minimum staffing requirements and utilizing all possible avenues to proactively increase staffing in the facility. Element #2 All residents have the potential to be affected by this deficient practice when staffing regulations are not met. Element #3 The staffing coordinator continues to utilize all possible means to increase facility staff, including offering bonuses to staff that refer to CNAs. The staffing coordinator will review the scheduled monthly staffing; any shift not adequately staffed, the staffing coordinator will reach out to our contracted staffing agencies, who assure us they will make all efforts to supply the necessary staff. In addition, the staffing coordinator can offer part-time/per-diem employment to our sister facility's CNA that may be seeking additional working hours. Staffing Coordinator, Nursing Director, and Administrator have listed job opportunities/openings on Indeed and Apploi for hiring nursing staff. Element #4 The Administrator or designee will monitor daily staffing levels with the staffing coordinator for the next 4 months (6/20/2025-10/20/2025). Weekly for the first 4 weeks and after 4 weeks, bi-weekly for 12 weeks. All findings to be reported and discussed by the next two QAPI meetings.
Failure to Meet Mandatory CNA Staffing Ratios
Penalty
Summary
The facility failed to meet the mandatory staffing ratios for Certified Nurse Aides (CNAs) as required by New Jersey law, specifically N.J.S.A. 30:13-18, during a 14-day review period. According to the findings, the facility was required to have at least one CNA for every eight residents on the day shift. However, for each of the 14 day shifts reviewed, the number of CNAs scheduled was consistently below the required minimum. For example, on multiple days, only 15 or 16 CNAs were present for 141 to 145 residents, when at least 18 CNAs were needed to meet the mandated ratio. This deficiency was identified through interviews and a review of facility staffing documents. The shortfall in CNA staffing was present on every day shift reviewed within the specified two-week period, affecting all residents in the facility. The report does not provide specific details about individual residents or their medical conditions, but it notes that the deficient practice had the potential to affect all residents due to the facility's failure to comply with state staffing requirements.
Plan Of Correction
1. Corrective Action for Residents Found to Have Been Affected: All staffing coordinators, unit managers, and scheduling personnel were re-educated on state staffing mandates and compliance tracking by the DON on 06/20/2025. 2. Identification of Other Residents Who May Be Affected: All residents in the facility during the day shift may have been affected by insufficient CNA staffing. 3. Measures and Systemic Changes to Prevent Recurrence: Staffing Recruitment: The facility has entered a new collective bargaining agreement as of 06/01/2025 with its union to increase wages $2.00 per hour. Daily Staffing Audits: The Director of Nursing (DON) or designee will review staffing ratios daily by shift and maintain a record to ensure compliance. Recruitment Campaign: A CNA recruitment initiative was launched including sign-on bonuses, referral incentives, job fairs, and outreach to local training programs including tuition sponsorship of nursing assistants, which has had successful outcomes. Through the sponsorship of Nursing Assistant training programs, the facility has successfully recruited and retained nursing assistants who received their Certified Nursing Assistant certification. A new recruiter started on 06/09/2025 who is actively engaging applicants through social media and on-the-spot interviews including weekends. Daily weekday meetings are held to discuss recruitment efforts. Retention Campaign: An employee survey was conducted of 95% of all staff, and results were received to facilitate feedback on actionable insights that help the facility understand, predict, and improve employee satisfaction and engagement to improve staff retention. Additionally, the facility has deployed human resource software through Retain. This software plays a proactive role in keeping employees engaged, utilized, and aligned with organizational goals. It minimizes turnover by addressing the root causes of attrition—overwork, disengagement, lack of growth, and misalignment between employee goals and business needs. Additionally, the facility has an active Employee of the Month program as well as team-building events to foster camaraderie and employee satisfaction. 4. Monitoring of Corrective Actions to Ensure Effectiveness: QAPI Oversight: Staffing ratio compliance will be tracked as a monthly Quality Assurance Performance Improvement (QAPI) indicator and results forwarded to the facility’s QAPI committee. Weekly Review: The DON will present a weekly staffing compliance summary to the Administrator for validation by 06/24/2025 for 30 days. 30-Day Audit: A 30-day audit (ending 07/24/2025) of CNA staffing ratios will be completed and submitted to the QAPI Committee for review and validation.
Failure to Meet Mandatory CNA Staffing Ratios
Penalty
Summary
The facility failed to meet the mandatory staffing ratios for Certified Nurse Aides (CNAs) as required by New Jersey law, specifically N.J.S.A. 30:13-18, during multiple day shifts over several weeks. According to the report, for the week of 06/23/2024 to 06/29/2024, the facility did not provide the minimum required number of CNAs on 5 out of 7 day shifts, with staffing levels ranging from 7 to 11 CNAs for 94 residents, when at least 12 were required. Additionally, for the two weeks prior to the survey (04/20/2025 to 05/03/2025), the facility was deficient in CNA staffing on 13 out of 14 day shifts, with CNA numbers consistently below the required minimum for the number of residents present. These deficiencies were identified through interviews and review of facility documents, and the lack of adequate CNA staffing had the potential to affect all residents in the facility. The report does not mention any specific residents or their medical histories, nor does it describe any direct harm or incidents resulting from the staffing shortages. The findings are based solely on the facility's failure to comply with the mandated CNA-to-resident ratios during the reviewed periods.
Plan Of Correction
1. The facility failed to ensure staffing ratios were met to maintain the required minimum staff to resident as mandated by the state of New Jersey. 2. All residents have the potential to be affected by this deficient practice. 3. The facility continues to actively fill all opened CNA (Certified Nursing Assistant) shifts to comply with New Jersey State mandated ratios. Minimum staffing requirements were reviewed with the Staffing Coordinator who was able to reiterate minimum staffing requirements for nursing homes. The facility Labor Management Team is focusing on recruitment and retention strategies by identifying vacant positions and attempting to fill positions with current CNA staff or agency. The Labor Management Team collaborates with the Corporate Recruiter to advertise, recruit, and hire sufficient CNA staff. The Labor Management Team continues to develop programs to attract and retain Certified Nursing Assistants. Examples of which include shift bonuses and collaborating with CNA schools to offer facility paid schooling. Partner with local CNA class instructors to identify potential students. In addition, the facility Labor Management Team promotes in-house programs to increase retention of current staff. 4. The facility Labor Management Team meets weekly to review the effectiveness of recruitment and retention programs and open labor positions. The findings from these meetings will be reviewed monthly for three months by the Quality Assurance Committee. Based upon the results of the findings, the Quality Assurance Committee will determine whether ongoing submission and reporting is needed.
Failure to Meet Mandatory CNA Staffing Ratios
Penalty
Summary
The facility failed to meet mandatory staffing ratios as required by New Jersey law for certified nurse aides (CNAs) and direct care staff. During a review of staffing records for a two-week period, it was found that the facility did not have the required number of CNAs on 12 out of 14 day shifts and was also deficient in total direct care staff on one evening shift. Specific examples include having only 17 CNAs for 176 residents on one day when at least 22 were required, and similar shortfalls on multiple other days. The facility also had one overnight shift where the total staff was below the required minimum. These deficiencies were identified through interviews and document reviews conducted during the complaint survey. The staffing requirements referenced are based on New Jersey statutes and regulations, which mandate specific CNA-to-resident ratios for each shift. The facility's failure to meet these ratios was documented for several consecutive days, with the number of CNAs consistently falling short of the minimum required for the number of residents present. The report does not mention any specific residents affected or detail any adverse outcomes, but it notes that the deficient practice had the potential to affect all residents in the facility.
Plan Of Correction
S560 Mandatory access to care ELEMENT 1 • The Staffing Coordinator was re-educated on New Jersey minimum staffing requirements for nursing homes. ELEMENT 2 • All residents have the potential to be affected by this practice. ELEMENT 3 The Staffing Coordinator will report staffing weekly to the Administrator / Director of Nursing / designee. Flyers are hung in staff areas advertising open staff positions. Indeed is used to advertise for open staff positions. Agencies are used to fill open staff positions. ELEMENT 4 Root cause analysis was conducted and a QAPI performance improvement project team formed to address staffing concerns. Staffing is discussed at weekday clinical meetings and concerns reported to the Licensed Nursing Home Administrator and Director of Nursing for follow-up. The Director of Nursing will report on staffing audits and any actions taken at the monthly Quality Assurance and Process Improvement Committee meetings for three months. Based on findings, a decision will be made regarding review and further directives. Date of Completion: June 9, 2025
Failure to Meet Minimum CNA Staffing Ratios on Day Shifts
Penalty
Summary
The facility failed to maintain the required minimum direct care staff-to-shift ratios as mandated by the state of New Jersey for 48 out of 63 day shifts reviewed. This deficiency was identified through interviews and a review of facility documentation, including staffing schedules for multiple periods. The state law requires one Certified Nurse Aide (CNA) for every eight residents during the day shift, but the facility consistently scheduled fewer CNAs than required for the number of residents present. Specific staffing shortfalls were documented across several weeks, with multiple day shifts where the number of CNAs on duty did not meet the minimum ratio. For example, on several occasions, there were only 13 to 15 CNAs scheduled for over 120 residents, when at least 15 or 16 were required. These deficiencies were present in all reviewed periods, including weeks in October, December, February, and April-May, with some periods showing every day shift falling below the required staffing level. During an interview, the staffing coordinator acknowledged awareness of the New Jersey staffing ratios and attributed short staffing primarily to last-minute call outs, though she stated it was rare for the facility to be short-staffed. The facility's own policy, revised in January, emphasized the need to provide sufficient staff to ensure resident safety and well-being, but the documented staffing levels did not align with these requirements during the reviewed periods.
Plan Of Correction
1. The daily staffing schedule was reviewed by the Human Resources Director to assure the facility is in compliance with the required minimum direct care staff-to-shift ratios. 2. All residents have the potential to be affected by the deficient practice. 3. The Human Resources Director will continue to post the vacancies on all 3 shifts. The Human Resources Director will continue to recruit through online platforms as well as a job fair. The Administrator will boost the rate when there is emergency staffing coverage. The facility is contracted with multiple staffing agencies for temporary and permanent staffing assistance. Employee Referral Bonus Program is in place. Bi-weekly meetings are held including the Administrator, Director of Nursing, Human Resources, staffing coordinator, and recruiter to review direct care staffing and develop strategies for recruitment and retention of direct care staff. In the event that we do not have the adequate ratio of staff on schedule or have call outs, the staff on shift are asked to stay for another shift as well as available coverage is requested from the facility's contracted staffing agencies at a boosted rate. 4. The Human Resources Director or designee will report the findings of completed direct care staff to resident ratio weekly audits to the Nursing Home Administrator as well as at the quarterly Quality Assurance and Performance Improvement meetings. The Quality Assurance Performance Improvement Committee will determine whether the audit needs to be continued or discontinued.
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
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
