Failure to Meet Mandatory Nurse Staffing Requirements
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
Penalty
The facility did not provide the minimum required nursing staff hours on two days, falling short of the mandated hours needed to care for all residents, including those requiring specialized services such as wound care, tube feedings, and respiratory support.
A review of nurse staffing reports revealed that the facility did not meet the minimum required staffing hours on one day, providing 480 hours instead of the required 484 hours. This deficiency was identified during the investigation of two complaints.
The facility did not provide the required minimum nurse staffing hours on three separate days, with actual staffing falling short of the calculated requirements based on resident census and specialized care needs. This deficiency was identified during the review of staffing reports related to multiple complaints.
The facility did not meet the required nurse staffing hours for one day during a two-week period, providing 1.5 hours less than mandated based on resident count and acuity. Despite scheduling efforts, including bonuses and agency staff, actual nursing hours fell short of the minimum required to meet resident care needs.
The facility did not meet mandatory nurse staffing requirements for two days in early December 2024, falling short by 33 and 9 hours, respectively. Despite claims from the Staffing Coordinator, DON, and Licensed Nursing Home Administrator that staffing was adequate based on census and resident acuities, the facility's policy to maintain adequate staffing was not fulfilled.
The facility did not meet the mandatory nurse staffing levels for two days during a two-week period, as required by N.J.A.C. 8:39-25.2(b)(1)&(2). On two separate days, the facility was short by 2.25 and 4 hours, respectively, in providing the necessary nursing services. This deficiency was noted in response to specific complaints.
Failure to Meet Mandatory Nurse Staffing Levels
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). Specifically, the review of Nurse Staffing Reports for the weeks of 04/20/2025 to 05/03/2025 revealed that on two out of fourteen days, the actual nursing staff hours provided were below the minimum required levels. On 04/27/25, the facility provided 416 actual staffing hours against a required 459.25 hours, resulting in a shortfall of 43.25 hours. On 05/03/25, the facility provided 440 actual staffing hours, which was 19.25 hours less than the required amount. These deficiencies were identified during the investigation of multiple complaints, as referenced by the complaint numbers listed in the report. The calculation of required staffing hours included both the base requirement per resident and additional hours for residents receiving specialized services such as wound care, tube feedings, oxygen therapy, tracheostomy care, intravenous therapy, respirator use, and advanced neuromuscular or orthopedic care. The report does not provide specific details about individual residents or their medical histories, but it documents the facility's failure to provide the mandated level of nursing care on the identified dates.
Plan Of Correction
S1680 Mandatory nurse staffing 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 daily 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 x 3 months. Based on findings, a decision will be made regarding review and further directives. Date of Completion: June 2025
Failure to Meet Minimum Nurse Staffing Requirements
Penalty
Summary
The facility failed to meet the minimum required nurse staffing levels for 1 out of 14 days during the review period. Specifically, on one day, the actual staffing hours provided were 480, which was 4 hours less than the required 484 hours. This deficiency was identified through a review of the Nurse Staffing Reports for the weeks of 03/23/25 and 03/30/25, as part of the investigation of two complaints (NJ182091, NJ185153). No additional details about specific residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Plan Of Correction
5/22/25 S1680 Mandatory Nurse Staffing 1. Corrective Action: - Staffings coordinator was educated by the DON, on New Jersey state staffing regulation related to nursing services by registered professional nurses, licensed practical nurses, and nurse's aide requirements on May 19, 2025. - Efforts to hire facility staff will continue until there is adequate staff to meet the minimum nursing staff to resident ratios. 2. Identification of other residents or areas having the potential to be affected due to the nature of this deficiency: - All residents have the potential to be affected by this deficient practice. 3. Measures Put in Place: - The administrator, DON/designee will review staffing schedules weekly to ensure adequate nursing staffing for all shifts. 4. How Will These Actions Be Measured: - The results of the weekly audits will be submitted to the Quality Assurance and Process Improvement Committee Meeting monthly for 6 months. Based on the results of these audits, a decision will be made regarding the need for continued submission and reporting. The next Quality Assurance and Process Improvement Committee Meeting will be held on June 6, 2025.
Failure to Meet Minimum 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 three out of fourteen days, as evidenced by a review of Nurse Staffing Reports for the weeks of 04/06/25 and 04/19/25. Specifically, on three separate days, the actual nursing staff hours provided were below the required minimum, with deficits of 17.25, 14.75, and 6.75 hours respectively. The required staffing hours were calculated based on the total number of residents and the additional care needs of residents receiving specialized services such as wound care, tube feedings, oxygen therapy, tracheostomy, intravenous therapy, use of respirator, and advanced neuromuscular or orthopedic care. This deficiency was identified during the investigation of complaints NJ181841, NJ178109, and NJ182273.
Plan Of Correction
Plan of Correction Root Cause: Upon review of the S1680 tag, the facility noted the root cause of this issue to be because the facility failed to ensure that it was staffed at least minimum staffing ratio based on its acuities. S1680 Immediate Corrective Action: The Facility cannot retroactively respond to this deficient practice. On 4/25/2025, the Administrator, Human Resource Director/Staffing Coordinator, and Director of Nursing conducted a root cause analysis based on the findings in the alleged deficient to ensure that the facility provides sufficient nurse staffing based on the total number of residents multiplied by 2.5 + the facility's current acuities. On 4/25/2025, the Administrator coordinated with the Director of Nursing and Human Service Director a review of the facility policy and procedure for ensuring adequate nursing service ratios that meet the facility acuity needs. On 4/25/2025, the Administrator conducted an in-service with the Human Resources and Director of Nursing on the facility policy and procedure for ensuring adequate nursing service ratios that meet the facility acuity needs. Identification of Others: An assessment of the risk this deficient practice could have on residents at this facility was completed by the administrator, Director of Nursing, and Staffing Coordinator, HR Manager, and it was found that all residents were impacted by this deficient practice. Systemic Change: The Facility Director of Nursing, Administrator, HR Manager initiated the following employee recruitment programs for the clinical department: - Rates increased - Offering our staff bonuses - Job Fair - Posting new ads around town and via social media - Staff Testimonial videos for recruitment - Referral bonuses for our staff - Referring to bonuses relationship with local CNA school to provide additional staffing support - Sign on bonus The Facility Human Resource Director will conduct a daily review of staffing schedules based on facility census and acuities to ensure adequate staffing and report findings to the administrator. On 4/25/2025, the Administrator coordinated with the Director of Nursing and Human Service Director a review of the facility policy and procedure for ensuring adequate nursing service ratios that meet the facility acuity needs. On 4/25/2025, the Administrator conducted an in-service with the Human Resources and Director of Nursing on the facility policy and procedure for ensuring adequate nursing service ratios that meet the facility acuity needs. Identification of Others: An assessment of the risk this deficient practice could have on residents at this facility was completed by the administrator, Director of Nursing, and Staffing Coordinator, HR Manager, and it was found that all residents were impacted by this deficient practice. Systemic Change: The Facility Director of Nursing, Administrator, HR Manager initiated the following employee recruitment programs for the clinical department: - Rates increased - Offering our staff bonuses - Job Fair - Posting new ads around town and via social media - Staff Testimonial videos for recruitment - Referral bonuses for our staff - Referring to bonuses relationship with local CNA school to provide additional staffing support - Sign on bonus The Facility Human Resource Director will conduct a daily review of staffing schedules based on facility census and acuities to ensure adequate staffing and report findings to the administrator. V. Quality Assurance: The Human Resource Director/designee will aggregate findings from these rounds daily for 1 month and then monthly for 3 months and review the findings with the administrator and submit to QA/QA committee for review. The QA/QAPI committee will meet monthly for the next 3 months and review all findings to assess whether further action is necessary.
Deficiency in Mandatory Nurse Staffing Hours
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 1 out of 14 days during the review period. Specifically, on one day, the actual nursing staff hours provided were 208, which was 1.5 hours less than the required 209.5 hours based on the total number of residents and the acuity-based care hours needed for services such as wound care, tube feedings, oxygen therapy, tracheostomy, intravenous therapy, use of respirator, and advanced neuromuscular/orthopedic care. The deficiency was identified through a review of the Nurse Staffing Reports for the specified two-week period. During an interview, the Licensed Nursing Home Administrator (LNHA) acknowledged awareness of the minimum staffing ratio requirements and stated that the facility scheduled staff to meet those needs, utilizing bonuses and agency staff as needed. The facility's "Sufficient Staffing" policy, revised prior to the deficiency, required sufficient nursing staff with appropriate competencies to meet resident care needs on a 24-hour basis, including the designation of a registered nurse responsible for overseeing nursing activities on each shift. Despite these policies and efforts, the facility did not meet the required staffing hours on the identified day.
Plan Of Correction
The facility cannot retroactively correct the deficient practice. However, the facility seeks to schedule staff based on the required staffing level to comply with the State of NJ staffing requirements. All residents have the potential to be affected. The Administrator initiated an in-service with the Director of Nursing (DON) and Staffing Coordinator on ensuring that the required staffing levels are provided and also reviewed the Sufficient Staffing policy. The DON and Staffing Coordinator will complete daily staffing sheets to ensure that the facility is meeting the required staffing levels per regulations. The DON, Staffing Coordinator, Administrator and or designee will monitor and review the daily Staffing Acuity Work Sheets weekly x 4 weeks and then monthly x 3 months to ensure that the daily required staffing levels were met. The results will be presented to, will be reported, reviewed by the DON, Staffing Coordinator and or designee and submitted to the monthly Quality Assurance and Performance Improvement Committee (QAPI) for three (3) months in order to determine if further interventions are needed.
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 two days during the week of December 1, 2024. Specifically, on December 1, 2024, the facility provided 480 actual staffing hours, which was 33 hours short of the required 513 hours. Similarly, on December 2, 2024, the facility provided 504 actual staffing hours, falling short by 9 hours. This deficiency was identified through a review of the Supplementary Nurse Staffing Report for the weeks of December 1, 2024, to December 14, 2024. Interviews conducted on December 20, 2024, with the Staffing Coordinator, Director of Nursing (DON), and the Licensed Nursing Home Administrator revealed differing perspectives on staffing adequacy. The Staffing Coordinator indicated reliance on the facility census for scheduling, while the DON asserted that registered nurses were available 24/7 and that staffing requirements were met. The Licensed Nursing Home Administrator emphasized staffing based on resident acuities, claiming the facility was correctly staffed. Despite these assertions, the facility's policy, revised in April 2024, stated that adequate staffing should be maintained to meet resident care needs, which was not achieved on the specified days.
Plan Of Correction
S1680- Mandatory Nurse Staffing What corrective action will be accomplished for those residents affected by the deficient practice? No residents were identified. How will the facility identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? All residents have the potential to be affected by the deficient practice. What measures will be put into place or what systemic changes will be made to ensure the deficient practice will not recur? On January 6, 2025, the Administrator provided re-education to the Director of Nursing, Assistant Director of Nursing, and the Human Resources Director on the minimum staffing requirements by shift for professional nurses and certified nurse aides (direct care staff) by the Department of Health. The Administrator, Director of Nursing, Human Resources Director, and/or Staffing Coordinator will meet weekly to review professional nurse and certified nurse aides staffing levels for the week, open positions, and recruitment efforts. The facility will focus on recruitment and retention including but not limited to, use of web-based recruitment advertising, contract utilization, sign-on bonuses and referral bonuses, job fairs, shift differentials, and employee moral incentives. The Human Resources Director will utilize the Recruitment Report to track and trend recruitment efforts weekly x4 weeks, then 2x a month for 2 months. How will the corrective action be monitored to ensure the deficient practice will not recur? The Human Resources Director and/or Designee will review and report the audit results during the Quality Assurance Performance Improvement (QAPI) meeting monthly x3 months. The QAPI meeting is attended by the Administrator, Director of Nursing, Medical Director, and Department Heads.
Nurse Staffing Deficiency Identified
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 two days during the weeks of 12/08/2024 and 12/21/2024. Specifically, on 12/08/2024, the facility provided 240 actual staffing hours, falling short by 2.25 hours from the required 242.25 hours. Similarly, on 12/15/2024, the facility provided 240 actual staffing hours, which was 4 hours less than the required 244 hours. This deficiency was identified based on the review of Nurse Staffing Reports and was associated with complaint numbers NJ00168416 and NJ00181485.
Plan Of Correction
1) How the corrective action will be accomplished for those residents found to have been affected by the deficient practice. The facility leadership team has met on an ongoing basis and continued to identify staffing challenges and areas of improvement for licenses and certified staffing needs. 2) How the facility will identify other residents having the potential to be affected by the same deficient practice. All residents have the potential to be affected by this practice. 3) What measures will be put into place or systemic changes will be made to ensure that the deficient practice will not recur. The DON conducted an audit of staffing schedules with the current facility census to ensure fulfillment of staffing requirements per shift. The facility has implemented an incentive program including referral bonuses for employees referring staff where appropriate, conducted job fairs, immediate interviews with contingency offers, and expedited the onboarding process of new hires. The facility has contracted a vendor with agency staff as needed to meet staffing needs. The Director of Nursing and Director of Rehabilitation continue to partner in addressing staffing challenges. Where appropriate, the occupational therapy staff assist in providing care and activities of daily living to residents. 4) How the facility will monitor its corrective actions to ensure that the deficient practice is being corrected and will not recur, i.e. what QA program will be put into place to monitor the continued effectiveness of the systemic change. The DON and/or designee will meet with the staffing coordinator daily to review facility census, call outs if any, and staffing needs. The DON and/or designee will monitor callouts and staffing ratios weekly until the requirement is met. The results of the audits will be forwarded to the facility Administrator and QAPI Committee for further review and recommendations as needed.
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.
