Failure to Meet CNA Staffing Ratios
Penalty
Summary
The facility failed to meet the mandatory staffing ratios as required by New Jersey state law, specifically during the day shifts. The deficiency was identified through a review of facility documentation, which revealed that the facility did not have the required number of Certified Nurse Aides (CNAs) on duty for 18 out of 21 day shifts. This failure to comply with staffing requirements was evidenced by specific instances where the number of CNAs was below the mandated ratio of one CNA to every eight residents. For example, during the week of August 4, 2024, to August 10, 2024, the facility was deficient in CNA staffing on five out of seven day shifts. On August 4, 2024, there were only 13 CNAs for 142 residents, whereas at least 18 CNAs were required. Similarly, in the two weeks prior to the survey from November 24, 2024, to December 7, 2024, the facility was deficient on 13 out of 14 day shifts. On December 7, 2024, there were only 8 CNAs for 127 residents, while at least 16 CNAs were needed. These deficiencies indicate a consistent failure to meet the staffing requirements set forth by the New Jersey Department of Health.
Plan Of Correction
Mandatory Access to Care 1. Corrective Action All residents have the potential to be affected by this deficient practice. Center is currently employing sign on bonuses, referral bonuses, and various other incentives for current staff to meet staffing standards. Nursing employees salaries were increased effective January 1, 2025. 2. All residents have the potential to be affected by this deficient practice. 3. Staffing coordinator was re educated on NJ staffing mandate. Center will continue recruiting functions, which drive various forms of media to increase the number of applicants. Continue to establish external partnerships with schools to train students and transition them into CNAs. Weekly labor management calls with regional support team. 4. The Labor management team will maintain a listing of current recruiting efforts, and document weekly the results of these efforts. The Administrator or designee will audit these efforts weekly x 4 weeks, then monthly x 2 to ensure the Center team is following up on all recruitment tasks. The Administrator or Designee will report findings to the Performance Improvement Committee monthly for three months. The Performance Improvement Committee will evaluate and determine the effectiveness of the plan to ensure substantial compliance is achieved and determine if further monitoring and evaluation is required.