Failure to Meet Minimum Staffing Ratios
Penalty
Summary
The facility failed to maintain the required minimum direct care staff to resident ratio as mandated by the State of New Jersey. This deficiency was identified during a recertification survey, which revealed that for two weeks prior to the survey, the facility did not meet the staffing requirements on six out of fourteen day shifts. Specifically, the facility was short of Certified Nurse Aides (CNAs) on multiple days, with the number of CNAs ranging from 10 to 15, whereas at least 16 CNAs were required for the number of residents present. Interviews with the Staffing Coordinator and the Director of Nursing confirmed that they were aware of the New Jersey minimum staffing requirements, which stipulate one CNA for every eight residents during the day shift. Despite this knowledge, the facility's staffing policy, revised in June 2024, which stated that staffing ratios would be reviewed and adjusted based on resident acuity and care needs, was not adhered to, resulting in the deficiency.
Plan Of Correction
1. No residents were affected by not meeting the State of NJ minimum staffing requirements as determined by routine monitoring and review on those dates that no significant changes were noted. 2. All residents could be affected by not meeting State of NJ minimum staffing requirements. 3. Recruitment and retention efforts continue to include: a. Job fairs b. Daily staffing meetings and weekly Regional Labor Management reviews c. Training mentor program to support retention d. Culture committee to improve and maintain staff morale 4. Recruitment bonus and sign-on bonuses offered. 5. Competitive wage analysis. 6. Hired Elite Recruiting to support increased recruiting of nurses and aides. 7. Weekend warrior program started. 8. To monitor and maintain ongoing compliance, the Director of Nursing or designee will monitor staffing daily for 1 week, weekly for 3 weeks, and monthly for 3 months. Results will be presented to the Quality Assurance and Performance Improvement team monthly for continued review and recommendations until substantial compliance is maintained.