Failure to Meet Mandatory CNA Staffing Ratios
Penalty
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 a 14-day review period. According to the findings, the facility was required to have at least one CNA for every eight residents on the day shift. However, for each of the 14 day shifts reviewed, the number of CNAs scheduled was consistently below the required minimum. For example, on multiple days, only 15 or 16 CNAs were present for 141 to 145 residents, when at least 18 CNAs were needed to meet the mandated ratio. This deficiency was identified through interviews and a review of facility staffing documents. The shortfall in CNA staffing was present on every day shift reviewed within the specified two-week period, affecting all residents in the facility. The report does not provide specific details about individual residents or their medical conditions, but it notes that the deficient practice had the potential to affect all residents due to the facility's failure to comply with state staffing requirements.
Plan Of Correction
1. Corrective Action for Residents Found to Have Been Affected: All staffing coordinators, unit managers, and scheduling personnel were re-educated on state staffing mandates and compliance tracking by the DON on 06/20/2025. 2. Identification of Other Residents Who May Be Affected: All residents in the facility during the day shift may have been affected by insufficient CNA staffing. 3. Measures and Systemic Changes to Prevent Recurrence: Staffing Recruitment: The facility has entered a new collective bargaining agreement as of 06/01/2025 with its union to increase wages $2.00 per hour. Daily Staffing Audits: The Director of Nursing (DON) or designee will review staffing ratios daily by shift and maintain a record to ensure compliance. Recruitment Campaign: A CNA recruitment initiative was launched including sign-on bonuses, referral incentives, job fairs, and outreach to local training programs including tuition sponsorship of nursing assistants, which has had successful outcomes. Through the sponsorship of Nursing Assistant training programs, the facility has successfully recruited and retained nursing assistants who received their Certified Nursing Assistant certification. A new recruiter started on 06/09/2025 who is actively engaging applicants through social media and on-the-spot interviews including weekends. Daily weekday meetings are held to discuss recruitment efforts. Retention Campaign: An employee survey was conducted of 95% of all staff, and results were received to facilitate feedback on actionable insights that help the facility understand, predict, and improve employee satisfaction and engagement to improve staff retention. Additionally, the facility has deployed human resource software through Retain. This software plays a proactive role in keeping employees engaged, utilized, and aligned with organizational goals. It minimizes turnover by addressing the root causes of attrition—overwork, disengagement, lack of growth, and misalignment between employee goals and business needs. Additionally, the facility has an active Employee of the Month program as well as team-building events to foster camaraderie and employee satisfaction. 4. Monitoring of Corrective Actions to Ensure Effectiveness: QAPI Oversight: Staffing ratio compliance will be tracked as a monthly Quality Assurance Performance Improvement (QAPI) indicator and results forwarded to the facility’s QAPI committee. Weekly Review: The DON will present a weekly staffing compliance summary to the Administrator for validation by 06/24/2025 for 30 days. 30-Day Audit: A 30-day audit (ending 07/24/2025) of CNA staffing ratios will be completed and submitted to the QAPI Committee for review and validation.