Failure to Meet CNA Staffing Ratios
Penalty
Summary
The facility failed to meet the mandatory staffing ratios as required by the State of New Jersey, specifically for the day shift. According to the New Jersey Department of Health memo dated 01/28/2021, the law mandates a minimum of one Certified Nurse Aide (CNA) for every eight residents during the day shift. However, during the survey conducted on 12/23/2024, it was found that the facility did not comply with these staffing requirements for 9 out of 14 day shifts between 12/01/2024 and 12/14/2024. The specific instances of non-compliance included having fewer CNAs than required for the number of residents present. For example, on 12/01/2024, there were 12 CNAs for 101 residents, whereas at least 13 CNAs were needed. Similar deficiencies were noted on other days, with the most significant shortfall occurring on 12/10/2024, when only 5 CNAs were available for 98 residents, requiring at least 12 CNAs. This consistent understaffing indicates a failure to adhere to the mandated staffing ratios, which is a violation of the state law.
Plan Of Correction
Residents affected by deficient practice: Facility failed to ensure staffing ratios were met to maintain the required minimum staff-to-resident ratio. No Residents were identified. Identify those individuals who could be affected by the deficient practice: All Residents have the potential to be affected. All Residents were monitored for any adverse effects with none noted. Director of Nursing, Human Resources, and Staffing Director were educated on the minimum staffing requirements by the administrator on 1/16/2025. What corrective actions will be accomplished for those residents affected by the deficient practice: The facility implemented an expedited, but robust onboarding process. The facility will use agency staff as needed to meet staffing needs. The facility will continue to participate in biweekly recruitment calls to review open positions, recruitment tactics, and changes to improve outcomes. All these efforts will provide an opportunity to meet the required staffing minimums. Measures or systemic changes to ensure that the deficiencies will not occur: Administrator/Designee will conduct two audits weekly for four weeks, then twice monthly for two months to ensure adequate staff is scheduled to accommodate resident needs. Results of the audits will be reviewed at the monthly quality assurance performance improvement meeting, and quarterly over the duration of the audit process 3 months to ensure compliance. Based on the results of these audits, a decision will be made regarding the need for continued submission and reporting.