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S0560

Failure to Meet Mandatory CNA Staffing Ratios

Ocean Grove, New Jersey Survey Completed on 05-15-2025

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 for Certified Nurse Aides (CNAs) as required by New Jersey law, specifically N.J.S.A. 30:13-18, during multiple day shifts over several weeks. According to the report, for the week of 06/23/2024 to 06/29/2024, the facility did not provide the minimum required number of CNAs on 5 out of 7 day shifts, with staffing levels ranging from 7 to 11 CNAs for 94 residents, when at least 12 were required. Additionally, for the two weeks prior to the survey (04/20/2025 to 05/03/2025), the facility was deficient in CNA staffing on 13 out of 14 day shifts, with CNA numbers consistently below the required minimum for the number of residents present. These deficiencies were identified through interviews and review of facility documents, and the lack of adequate CNA staffing had the potential to affect all residents in the facility. The report does not mention any specific residents or their medical histories, nor does it describe any direct harm or incidents resulting from the staffing shortages. The findings are based solely on the facility's failure to comply with the mandated CNA-to-resident ratios during the reviewed periods.

Plan Of Correction

1. The facility failed to ensure staffing ratios were met to maintain the required minimum staff to resident as mandated by the state of New Jersey. 2. All residents have the potential to be affected by this deficient practice. 3. The facility continues to actively fill all opened CNA (Certified Nursing Assistant) shifts to comply with New Jersey State mandated ratios. Minimum staffing requirements were reviewed with the Staffing Coordinator who was able to reiterate minimum staffing requirements for nursing homes. The facility Labor Management Team is focusing on recruitment and retention strategies by identifying vacant positions and attempting to fill positions with current CNA staff or agency. The Labor Management Team collaborates with the Corporate Recruiter to advertise, recruit, and hire sufficient CNA staff. The Labor Management Team continues to develop programs to attract and retain Certified Nursing Assistants. Examples of which include shift bonuses and collaborating with CNA schools to offer facility paid schooling. Partner with local CNA class instructors to identify potential students. In addition, the facility Labor Management Team promotes in-house programs to increase retention of current staff. 4. The facility Labor Management Team meets weekly to review the effectiveness of recruitment and retention programs and open labor positions. The findings from these meetings will be reviewed monthly for three months by the Quality Assurance Committee. Based upon the results of the findings, the Quality Assurance Committee will determine whether ongoing submission and reporting is needed.

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