Failure to Meet Mandatory CNA Staffing Ratios
Penalty
Summary
The facility failed to meet mandatory staffing ratios as required by New Jersey law for certified nurse aides (CNAs) and direct care staff. During a review of staffing records for a two-week period, it was found that the facility did not have the required number of CNAs on 12 out of 14 day shifts and was also deficient in total direct care staff on one evening shift. Specific examples include having only 17 CNAs for 176 residents on one day when at least 22 were required, and similar shortfalls on multiple other days. The facility also had one overnight shift where the total staff was below the required minimum. These deficiencies were identified through interviews and document reviews conducted during the complaint survey. The staffing requirements referenced are based on New Jersey statutes and regulations, which mandate specific CNA-to-resident ratios for each shift. The facility's failure to meet these ratios was documented for several consecutive days, with the number of CNAs consistently falling short of the minimum required for the number of residents present. The report does not mention any specific residents affected or detail any adverse outcomes, but it notes that the deficient practice had the potential to affect all residents in the facility.
Plan Of Correction
S560 Mandatory access to care ELEMENT 1 • The Staffing Coordinator was re-educated on New Jersey minimum staffing requirements for nursing homes. ELEMENT 2 • All residents have the potential to be affected by this practice. ELEMENT 3 The Staffing Coordinator will report staffing weekly to the Administrator / Director of Nursing / designee. Flyers are hung in staff areas advertising open staff positions. Indeed is used to advertise for open staff positions. Agencies are used to fill open staff positions. ELEMENT 4 Root cause analysis was conducted and a QAPI performance improvement project team formed to address staffing concerns. Staffing is discussed at weekday clinical meetings and concerns reported to the Licensed Nursing Home Administrator and Director of Nursing for follow-up. The Director of Nursing will report on staffing audits and any actions taken at the monthly Quality Assurance and Process Improvement Committee meetings for three months. Based on findings, a decision will be made regarding review and further directives. Date of Completion: June 9, 2025