Failure to Meet Mandatory Nurse Staffing Levels
Penalty
Summary
The facility failed to meet the mandatory nurse staffing requirements as outlined in N.J.A.C. 8:39-25.2(b)(1)&(2). Specifically, the review of Nurse Staffing Reports for the weeks of 04/20/2025 to 05/03/2025 revealed that on two out of fourteen days, the actual nursing staff hours provided were below the minimum required levels. On 04/27/25, the facility provided 416 actual staffing hours against a required 459.25 hours, resulting in a shortfall of 43.25 hours. On 05/03/25, the facility provided 440 actual staffing hours, which was 19.25 hours less than the required amount. These deficiencies were identified during the investigation of multiple complaints, as referenced by the complaint numbers listed in the report. The calculation of required staffing hours included both the base requirement per resident and additional hours for residents receiving specialized services such as wound care, tube feedings, oxygen therapy, tracheostomy care, intravenous therapy, respirator use, and advanced neuromuscular or orthopedic care. The report does not provide specific details about individual residents or their medical histories, but it documents the facility's failure to provide the mandated level of nursing care on the identified dates.
Plan Of Correction
S1680 Mandatory nurse staffing 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 daily 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 x 3 months. Based on findings, a decision will be made regarding review and further directives. Date of Completion: June 2025