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S0560

Staffing Ratio Deficiency in LTC Facility

Livingston, New Jersey Survey Completed on 01-09-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

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. During the investigation of complaints NJ00179449, NJ00179546, and NJ00181407, it was found that the facility did not have the required number of Certified Nurse Aides (CNAs) on several day shifts. For the period from August 11, 2024, to August 24, 2024, the facility was deficient in staffing on five out of fourteen day shifts. For instance, on August 11, 2024, there were only 15 CNAs for 130 residents, whereas at least 16 were required. Similar deficiencies were noted on August 21, 22, 23, and 24, 2024, where the number of CNAs was consistently below the required ratio. Additionally, a review of staffing levels for the two weeks prior to the complaint survey, from December 22, 2024, to January 4, 2025, revealed a deficiency on one day shift. On December 22, 2024, the facility had 14 CNAs for 120 residents, falling short of the required 15 CNAs. These staffing deficiencies had the potential to affect all residents in the facility, as adequate staffing is crucial for ensuring proper care and safety for residents.

Plan Of Correction

No residents were identified as having been affected. All residents have the potential to be affected. Will add a certified nursing aide to all shifts that did not meet the requirement to be in compliance with staffing ratio of 1:8 during daytime hours, 1:10 for afternoon, and 1:14 for overnight. When an employee calls out coverage to be obtained by nursing supervisor and Director of Nursing. Director of Nursing, Staffing Coordinator and Administrator will meet daily during the week to review recruitment efforts, staffing for next day, and staffing for upcoming week. Trends identified from these meetings will be presented during monthly QAPI meeting. The facility has implemented a multifaceted approach for recruitment and retention of employees, which includes increased utilization of PRN/Per diem staff (Staff hired without any set hours, usually staff who have another job and pickup extra shifts when the need arises), Multimedia advertisements, Partnership with schools, Pick-up shift bonuses, Text message campaigns. Flyers placed around the buildings and on social media. The facility continues to utilize a recruitment company to do paid campaigns with Indeed, and other social media platforms to recruit nursing staff. Daily update emails and weekly meetings help to identify trends in hiring and review all new hires and where candidates stand in the hiring process. Targeted advertising in place to attract licensed nurses and aides. Employee engagement is led by management team/department heads to facilitate staff engagement and reduce employee turnover. Exit interviews being held to determine why staff are leaving. Referral bonus in place for any staff who refer a friend who gets hired, new hire bonus in place and paid out over a year of hire to ensure that employees stay in the position.

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