Failure to Meet Minimum CNA 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 for one out of fourteen day shifts reviewed. Specifically, on one day shift, there were only 10 Certified Nurse Aides (CNAs) present for 87 residents, whereas the required minimum was 11 CNAs. This deficiency was identified through a review of the facility's "Nursing Staffing Report" for the specified weeks. During an interview, the Staffing Coordinator stated she was familiar with the CNA staffing ratios and believed the facility was able to meet them. The facility's staffing policy, reviewed in January 2025, indicated that staffing assignments were developed in accordance with resident needs and relevant regulations. However, the documentation and staffing records reviewed by the surveyor demonstrated that the facility did not meet the mandated CNA-to-resident ratio for at least one shift.
Plan Of Correction
Element #1 The staffing coordinator was in-serviced on 6/20/2025 by the Administrator and Nursing Director; education provided included the importance of meeting the minimum staffing requirements and utilizing all possible avenues to proactively increase staffing in the facility. Element #2 All residents have the potential to be affected by this deficient practice when staffing regulations are not met. Element #3 The staffing coordinator continues to utilize all possible means to increase facility staff, including offering bonuses to staff that refer to CNAs. The staffing coordinator will review the scheduled monthly staffing; any shift not adequately staffed, the staffing coordinator will reach out to our contracted staffing agencies, who assure us they will make all efforts to supply the necessary staff. In addition, the staffing coordinator can offer part-time/per-diem employment to our sister facility's CNA that may be seeking additional working hours. Staffing Coordinator, Nursing Director, and Administrator have listed job opportunities/openings on Indeed and Apploi for hiring nursing staff. Element #4 The Administrator or designee will monitor daily staffing levels with the staffing coordinator for the next 4 months (6/20/2025-10/20/2025). Weekly for the first 4 weeks and after 4 weeks, bi-weekly for 12 weeks. All findings to be reported and discussed by the next two QAPI meetings.