Failure to Meet Minimum 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 during a review of the facility's Nurse Staffing Reports, which revealed that on three separate day shifts, the facility did not meet the required staffing levels. Specifically, on one day shift in March 2024, the facility had 11 CNAs for 93 residents, falling short of the required 12 CNAs. Similarly, in November 2024, the facility had 10 CNAs for 85 and 86 residents on two separate day shifts, where at least 11 CNAs were required. Interviews with the facility's Staffing Coordinator and the Licensed Nursing Home Administrator, along with the Director of Nursing, confirmed awareness of the staffing regulations. The Staffing Coordinator mentioned that when staffing was deficient, they would send out "massive" texts to employees and, if necessary, use agency staff. Despite these efforts, the facility still failed to meet the mandated staffing ratios on the specified days, leading to the identified deficiency.
Plan Of Correction
1. There was no care issues reported on the three-day shifts of the twenty-one reviewed that the facility failed to maintain the required minimum direct care staff-to-resident ratios as mandated by the state of New Jersey. The Director of Nursing/designee reviewed the last 30 days of the Certified Nursing Assistant staffing report. The interdisciplinary team reviewed the grievance logs and care conference meetings, and no care issues were identified. 2. All residents have the potential to be affected by staffing below state mandated minimum levels. 3. Administrator in-serviced the staffing coordinator regarding the requirement for S560 to ensure Certified Nursing Assistant staffing needs are reviewed daily and addressed as needed to meet the staffing requirement. Recruitment efforts are in place to assist the facility in recruiting. Certified Nursing Assistant receive sign-on bonuses, referral bonuses, reimbursement for Certified Nursing Assistant tuition, and transportation service from certain locations. Facility also has contracts with agencies to recruit Certified Nursing Assistants. The Director of Nursing/designee also reviews staff attendance records to ensure that excessive absences are addressed accordingly. 4. The Administrator/designee will have weekly meetings with the staffing coordinator to audit staffing schedules, needs, and the efficacy of the systems in place to fill needs weekly. The findings of the audits will be presented at the QAPI meetings for three months.