Inadequate Staffing Levels Compromise Resident Care
Summary
The facility failed to ensure sufficient nursing staff to meet the needs of its residents, as evidenced by multiple complaint investigations and observations. The facility's staffing levels were consistently below the required minimums, with reports indicating that the average hours of care per resident per day were significantly lower than the mandated 3.5 hours. Observations and interviews revealed that call lights were left unanswered for extended periods, and residents were not receiving timely assistance with basic needs such as repositioning, toileting, and meal service. Interviews with staff members, including CNAs and LPNs, highlighted the challenges faced due to inadequate staffing. Staff reported being unable to complete their duties, such as providing showers, toileting residents, and assisting with meals, due to the high resident-to-staff ratios. The lack of sufficient staff also led to delays in medication administration and inadequate supervision of residents, particularly those with higher acuity needs or behavioral issues. Residents and their families expressed dissatisfaction with the care provided, citing long wait times for assistance and unmet care needs. The Resident Council and Ombudsman also reported concerns about staffing levels, with residents describing instances where call lights were ignored, and staff were unable to provide timely care. The facility's failure to maintain adequate staffing levels compromised the safety and well-being of its residents, as evidenced by the numerous complaints and observations documented in the report.
Plan Of Correction
Plan of Correction: Approved February 20, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice: The following corrective actions for those residents who were found to have been affected by the deficient practice: Five complaint investigations were conducted (#NY 668, #NY 735, #NY 153, #NY 833, and #NY 434) during annual survey which ended on 1/21/25. It was determined that the facility allegedly did not ensure that there was sufficient staffing on multiple dates throughout the [AGE] year, based on the previously referenced complaints and staff/resident interviews conducted during the annual survey. No residents were affected by this deficient practice. The Social Service Director/designee will review with all residents who are alert and oriented in person and/or will contact the responsible parties of those residents with cognitive impairment, to discuss the facility's active plan to recruit and retain staff. The recruitment and retention plan will be reviewed at the next resident council meeting. The Administrator/designee will also discuss the “Ambassador program” that was created to foster relationships between management team members and new staff. The facility also has a “Manager on Duty” program to assist on weekends with staffing challenges; this includes the majority of management in the facility. Nursing leadership coverage rotates on a weekly basis, with all members of the nursing leadership team assisting with off-hour and weekend assistance. The Daily Nursing report (BIPA) is reviewed daily to ensure the number of nursing hours worked and the number of nursing staff working each shift based on census met the minimum staffing requirements. The facility will work with the Corporate Recruitment manager to discuss alternative recruitment initiatives. How you will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken: The Director of Nursing/Assistant Director of Nursing ensure the health and wellbeing of the residents by having responsibility for oversight and operations of the nursing department. The DON and ADON, along with the Unit Nursing Managers, have been present on many shifts over the course of the last year. These include occasions when there were call-offs, weather-related issues, and other staffing challenges to help ensure adequate clinical specialists were on-site to provide care to the residents. The facility assessment and minimum staffing plan was reviewed and revised on 2/12/25 to include the use of a supplemental staffing agency. The Emergency Preparedness plan was reviewed on 2/12/25 to address staffing, which includes the use of a supplemental staffing agency. The facility labor disruption policy was reviewed on 2/12/25 to ensure interventions to address insufficient staffing are identified and staff will be re-educated on the process of when to activate the emergency staffing plan. When resident census changes, when staff call off or additional staff are called in to assist with staffing, the number of nursing hours worked, the number of nursing staff working each shift, and census will be updated on the Daily Nursing Report Sheets (BIPA). The Daily Nursing Report sheets along with the Facility Assessment minimum staffing ratios identified in the Facility Assessment will be compared to the daily clinical staffing sheets to ensure clinical daily schedules adequately reflect that staffing minimum hours are being achieved every shift according to the facility assessment. The Administrator, the DON, and the Staffing Coordinator will continue to review staffing daily and implement procedures to ensure sufficient staff are available to meet residents’ needs. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur: To ensure that this deficient practice does not re-occur, the Administrator/Director of Nursing will provide educational training consisting of but limited to: 1. Facility policy and procedures on Facility Wide Assessment Tool consisting of the facility's clinical minimum staffing requirements. 2. Facility policy and procedures on Labor Disruption Policy and when to activate plan. 3. Facility policy and procedures on Emergency Staffing Plan and when to activate the plan. 4. Facility policy and procedures on completing and reviewing the Daily Nursing Report Sheet. 5. Nursing Managers and Nursing Supervisors will be re-educated on procedures when to notify the Administrator, Director of Nursing, and the Assistant Director of Nursing when there are vacancies and nursing call-offs that impact the facility not meeting minimum clinical staffing requirements as identified on the Facility Assessment. 6. All in-services will be completed by 3/12/2025. Nursing Unit Managers, Nursing Supervisors, and all other nursing exempt staff will be educated by the Administrator/Director of Nursing on the facility's minimum staffing numbers identified in the facility assessment and what to do if the numbers drop below the minimum requirements. This will include what to do, who to call regarding call-offs/no call no shows, and what other nursing personnel to contact to try and fill the vacancy issues when dropping below minimum staffing requirements. A new on-call schedule was developed to provide to backfill vacancies that are unable to be filled. The on-call schedule does not include the DON as the facility census is above 60. Discussions regarding recruitment and retention initiatives will be added to the monthly resident council meeting agenda for three months. Grievances will be reviewed daily for staffing concerns during morning report. The Clinical Staffing Coordinator will audit the daily staffing sheets, the daily nursing report sheets (BIPA), the facility assessment minimum staffing ratios, and the daily census daily for three months to ensure minimum staffing compliance. The Administrator in conjunction with the Director of Nursing will continue to review the facility's schedules weekly for three months to ensure sufficient staff have been scheduled to attain and maintain the highest practicable physical, mental, and psychosocial well-being of residents. With support from the Corporate Recruitment Team and Chief Operating Officer involvement, continued Recruitment meetings will take place weekly to monitor recruitment initiatives. The facility will continue to provide daily staffing needs updates to the Staffing Agency vendor to try and fill daily open shifts. How the corrective action(s) will be monitored to ensure the deficient practice will not recur, i.e., what quality assurance program will be put into practice: Results of all audits will be submitted to the QA committee for review and results will be reviewed monthly. The administrator will be responsible for overseeing the completion of this plan of correction and will be completed on (MONTH) 12, 2025.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Insufficient nursing staff were present on a unit when a resident who required 2-person assist for ambulation and toileting was found walking from the bathroom to bed alone after waiting for help. At the time, only an LPN and a clerk were observed on the unit, while other NA staff had already punched out and the second nurse was charting on another unit.
Insufficient CNA Staffing and Delayed Resident Care: Residents and staff reported that CNA coverage was inadequate on evenings, nights, and weekends, leading to delayed call light response and unmet care needs. A resident with impaired mobility and another with CVA-related deficits reported long waits for assistance, while a CNA stated she was the only CNA on a hall overnight and had not been able to check many rooms. The Administrator and CNA Supervisor acknowledged staffing shortages, especially on nights and weekends, and resident council and grievance records also documented concerns about short staffing.
Insufficient nursing staffing led to delayed and incomplete resident care. The facility scheduled fewer CNAs than required by its assessment, often leaving only 5 to 6 CNAs on day shift instead of 8, and staff were told to cancel shifts when census dropped. Residents reported long waits for toileting and assistance, including being left in feces and waiting during meals for help, while CNAs described working alone, delayed call light response, missed or delayed ADL care, and difficulty completing 2-person transfers and mechanical lifts.
Delayed response to activated call lights was identified for a resident with intact cognition who required assistance with toileting, transfers, and ambulation and had care plan interventions for impaired mobility, safety, weakness from TIA, and fall risk. The resident reported staff often shut off the call light without providing help, and alarm records showed multiple response times over 15 minutes, including several lasting more than 30 minutes and up to nearly an hour. Staff and the DON acknowledged that response times had exceeded the expected timeframe, and the facility policy required staff to respond to engaged call lights in a timely manner.
A resident with a PEG tube, dysphagia, dementia, epilepsy, and other neurologic conditions had scheduled meds ordered through the tube, but the eMAR showed no meds documented for an entire evening med pass. The RN/UM said she worked a double shift because of a nursing call-out and forgot to document the meds as given, and the DON acknowledged the missed documentation.
Insufficient nursing staffing and delayed call light response were identified after residents reported waits of 30 minutes to 2 hours for assistance, including one resident left in the bathroom for 45 minutes and another with a 55-minute wait after activating a call light. The CNA scheduler said staffing was based on a corporate PPD target of 2.85 hours per resident rather than acuity, and records showed multiple weekend shifts with CNA, UM, and RN call-offs or no-shows. Residents also reported staff sitting in the lounge, not responding to lights, and unmet toileting and care needs.
Insufficient nursing staff on unit
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of every resident and to have a licensed nurse in charge on each shift. During an observation on 7/7/26 from 6:54 a.m. through 7:02 a.m., only LPN Employee E10 and the 2A clerk were observed on the nursing unit, while the resident room bathroom call light for Resident R239 was illuminated. At 7:03 a.m., Resident R239 was observed ambulating from the bathroom to bed by herself and stated she got tired of waiting for help. LPN Employee E10 then went to assist her because there were no other staff on the unit. Resident R239's plan of care identified that she required assistance of two staff for ambulation and toileting. Review of 11 p.m. to 7 a.m. staff punch-out times showed one NA punched out at 6:48 a.m., one NA punched out at 6:58 a.m., and two others punched out with the supervisor at 7:00 a.m.; the first NA for the 7 a.m. to 3 p.m. shift was observed on the unit at 7:02 a.m. During interview, the Nursing Supervisor stated the second nurse for the 2A unit was on 2B charting and no other staff were on the unit. The Nursing Home Administrator later confirmed that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for Resident R239.
Insufficient CNA Staffing and Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet residents’ needs in a timely manner and failed to have enough CNA coverage on evenings, nights, and weekends. The report states the facility had 108 residents and could not provide a staffing policy. Interviews with the Administrator and CNA Supervisor confirmed that nights and weekends were the hardest shifts to fill, that staff shortages were common, and that administrative staff were being used to help cover evening hours when CNA shifts were not fully staffed due to call-ins or no-shows. The CNA Supervisor also stated that optimal staffing on the 200 hall would be two CNAs on all shifts because many residents required two-person assistance with mechanical lifts. Several residents described delayed responses to call lights and assistance needs. One resident with diagnoses including acute respiratory failure, diabetes mellitus, anemia, anxiety disorder, and cognitive communication deficit stated the call light system was not working and that she had been given a whistle to use instead; she reported prolonged waits for staff response, especially after dinner and overnight, and said she had had incontinence episodes while waiting. Another resident with cerebral infarction, hemiplegia, major depressive disorder, and cognitive communication deficit stated she waited longer in the evening and overnight when using the call light, and that weekends seemed to have less staff available. A family member present during that interview stated staff worked hard but did not have enough help, especially on second shift and weekends. A third resident with anemia, muscle weakness, and need for assistance with personal care stated her call light system did not work and she had been given a dinner bell to use when needing assistance. She reported waiting 30 minutes or more for help with her incontinence brief during evening and overnight hours. A CNA working the night shift stated she was the only CNA assigned to the 200 hall at that time, that only 5 CNAs total were working nights including the supervisor, and that she had only checked 4 rooms since arriving before 2:00 AM, with 8 rooms or 11 residents still not checked on her hall. Resident council minutes also documented concerns that there were not enough CNAs on weekends, and a grievance form documented a resident complaint about not receiving a shower due to short staffing.
Insufficient Nursing Staffing and Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff in accordance with its facility assessment and residents’ care needs. The assessment called for 1 RN, 2 LPNs, and 8 CNAs on day shift; 3 LPNs and 8 CNAs on evening shift; and 3 CNAs plus 2 additional staff on night shift. However, the nursing schedule from June 2026 through July 3, 2026, showed no days with 8 CNAs assigned to the day or evening shift, with day shift typically staffed by only 5 to 6 CNAs. On one day, a note next to two staff names stated, “If all show, go home,” leaving only 5 CNAs on the floor. On another day, one CNA called off and was not replaced, leaving 3 CNAs for the 100-400 units and 1 CNA for the villa. Residents and staff described delays in care and difficulty meeting basic needs because of the staffing levels. One resident, who had multiple diagnoses including multiple sclerosis, trigeminal neuralgia, convulsions, malnutrition, COPD, hypotension, and epilepsy, was dependent on staff for ADLs and reported being left in feces for 45 minutes because no one was available to assist. The resident also reported that during meal times, call lights were not answered until meals were finished because aides were feeding residents and no one else was available. Another resident, who was dependent on staff for ADLs and had diagnoses including hemiplegia, chronic pain, depression, and falls, stated that the facility was short-staffed and that CNAs were stressed and unable to perform their jobs as they should. Multiple CNAs and the DON confirmed the staffing shortages and the effect on resident care. CNAs reported working alone in the villa, being told no additional CNA would be assigned until census exceeded 18, waiting for help with two-person transfers and mechanical lifts, delayed call light response times of up to 25 minutes, and residents being left soaked in urine overnight because there was not enough staff. The DON stated he wanted additional nurses and CNAs but was told to cancel staff when census dropped. The facility’s fall list also showed an increase in unwitnessed falls from 3 in May 2026 to 15 in June 2026.
Delayed Response to Resident Call Lights
Penalty
Summary
The facility failed to consistently respond to activated call lights within a timely manner for one resident. Resident #47 had a BIMS score of 15 out of 15 and required partial/moderate assistance with toileting hygiene and toilet transfers. The resident’s care plan identified impaired mobility, safety concerns, functional performance deficits related to weakness from a transient ischemic attack, and risk for falls, with interventions directing staff to keep the call light within reach, encourage use of it for assistance, and provide prompt response to requests for help. During observation, Resident #47 stated the call light had been activated for several minutes and was shut off by staff without assistance being provided, and the resident reported this happened often. Staff F acknowledged shutting off the call light when unable to assist the resident to the bathroom. Review of the facility’s excess response alarms showed multiple call light response times for Resident #47 ranging from 16.7 minutes to 57.3 minutes. Staff interviews confirmed that an appropriate response time was under 15 minutes, and the DON acknowledged that call lights had exceeded 15 minutes at times. The facility policy stated all staff were to respond to an engaged call light to rule out an emergency situation and that resident needs such as transfers, toileting, and dressing were to be addressed in a timely manner.
Missing Medication Documentation After Short-Staffed Shift
Penalty
Summary
The facility failed to provide sufficient nursing staff to ensure that medications and treatments were properly documented for one resident. Resident #47 had diagnoses including late effects of cerebral infarction, aphasia following cerebral infarction, dysphagia, dementia, epilepsy, hypertension, and gastrostomy status. The resident’s MDS indicated the resident was rarely or never understood and had a tube feeding. Physician orders included multiple scheduled medications administered via PEG tube and enteral feeding orders. Review of the eMAR for the evening shift showed no medications documented as administered for the entire medication pass. The medical record did not contain a nursing progress note explaining that the resident was out of the facility, refused medications, or otherwise accounting for the missing documentation. The RN/UM stated she worked a double shift because of a nursing call-out and, while working as the med nurse, forgot to document that the medications had been administered during the evening shift. The DON acknowledged that the RN/UM had worked two consecutive shifts due to a call-out and forgot to document administering the resident’s medications during the evening med pass.
Insufficient Nursing Staffing and Delayed Call Light Response
Penalty
Summary
The facility failed to provide enough nursing staff every day to meet resident needs and failed to ensure a licensed nurse was in charge on each shift. During a confidential resident group meeting, residents reported that call light response times were commonly about 30 minutes, could be as long as two hours, and that one resident had been left in the bathroom for 45 minutes before yelling for help. Residents also stated that the facility needed more staff and that staff called in too often. During interviews and record review, the surveyor learned that the facility used a corporate per-patient-day guideline of 2.85 hours per resident and did not use resident acuity in scheduling. The CNA/staff scheduler stated that management did not want staffing to go over or under that target and that she scheduled as close to it as possible. She also stated that weekend staffing was stacked to anticipate call-offs, and that residents had reported only one CNA on night shift, although she said clock-in records did not show that. She further stated that 3rd shift staff were in the lounge watching TV and not responding to call lights, and that the cameras did not work. Payroll and staffing records showed multiple weekend shifts with call-offs and short staffing across CNA, unit manager, and licensed nurse shifts, including several dates with multiple call-ins or no-shows on 1st, 2nd, and 3rd shifts. Residents reported long waits for call lights, unmet toileting needs, and staff not responding or returning after entering rooms. One resident’s concern form documented a 55-minute wait after a call light was activated, and another resident stated that staff did not respond for 30 minutes to 3 hours. The DON, regional clinical consultant, and NHA all acknowledged that PBJ staffing was submitted at the corporate level, and the NHA was aware of excessively low weekend staffing that had triggered in March 2026.
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