Weekend Staffing Shortages Impact Resident Care
Summary
The facility was found to have insufficient nursing staff to meet the needs of residents, particularly on weekends, as documented during a Recertification Survey and Complaint Survey. The facility's policy on staffing levels, revised in February 2024, aimed to ensure adequate and competent staffing based on the Facility Assessment. However, the Payroll Based Journal Staffing Data Report for the fourth quarter of 2024 indicated excessively low staffing levels on weekends. The facility's staffing plan outlined specific numbers of licensed nurses and certified nursing assistants required per shift, but actual staffing schedules revealed consistent shortages, particularly on weekends. Interviews with residents and staff corroborated the findings of understaffing. Several residents reported delays in receiving care, such as incontinence care, assistance with dressing, and meal delivery, due to the lack of sufficient staff. One resident mentioned that the issue was more pronounced on weekends, while another resident's representative noted that understaffing affected timely feeding during mealtimes. Certified Nursing Assistants also reported that being short-staffed led to delays in providing morning care and other essential services. The facility's Director of Nursing and Administrator acknowledged the staffing issues, attributing them to increased callouts during the summer months and the inability to replace absent staff. Despite these acknowledgments, both denied receiving complaints from residents or staff regarding staffing levels. The facility's staffing coordinator was uncertain about the extent of understaffing and noted that the facility did not offer incentives for staff to cover short-staffed shifts.
Plan Of Correction
Plan of Correction: Approved March 5, 2025 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This provider submits the following plan of correction in good faith and to comply with Federal Law. This plan is not an admission of wrongdoing, nor does it reflect agreement with the facts and conclusions stated in the statement of deficiencies. 1) Immediate actions taken for those residents identified: Bensonhurst Center will provide sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain and maintain the highest practicable physical, mental and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and [DIAGNOSES REDACTED]. No negative outcomes were identified for the residents noted in this citation (Resident #120, Resident #3, Resident #36, and Resident #43) as the result of this alleged deficient. All four residents continue to remain in the facility for long term care. None of them had any falls, weight loss or otherwise negative decline due to weekend staffing. 2) How the facility identified other residents: A combination of 20 Family Members/Residents were asked a 3-question survey week of (MONTH) 23rd. 14 Residents and 6 Family Members were surveyed: 1. Have you waited longer for care on weekends? 2. Have you noticed fewer staff on weekends (aside from management that don’t work weekends)? 3. Do you wish to file any grievance regarding care over the weekends? All responded no to these questions. Copies of these surveys are kept for verification. A review of weekend staffing over the last 2 weeks shows that each day fell within the parameters of the updated Facility Assessment. A Resident Council Meeting was held on 3/4/2025 to discuss the weekend staffing. 3) Measures put into place/System changes: 1. Facility Assessment was reviewed, revised, and updated to reflect current resident population acuities and staffing pattern needs on a 7-day basis. 2. A review of the master schedule was conducted and the facility identified all FT/PT openings. A union required posting for open shifts was posted at the facility time clock and was advertised on employment platforms. HR is actively recruiting for these open positions. 3. Two Nursing orientations were conducted since Survey exit. 4. Staffing Coordinator was educated on the appropriate staffing ranges that are required on a daily basis to ensure compliance with Facility Assessment. 5. On a weekly basis, the DON/Admin will review the weekend schedule between Thursday and Friday and devise a plan to ensure compliance with weekend staffing needs. This plan may include offering OT, mandating staff, requiring Management staff to work over the weekend or other potential interventions. 6. All nursing supervisors were educated to the above plan which they are empowered to implement (offering OT, mandating and other interventions). Furthermore, they were educated to notify DON/Admin should staffing fall below the requirements as identified in the Facility Assessment. 4) How the corrective actions will be monitored: An audit tool has been created, which will be completed weekly x8 weeks and then monthly x 6 months. This tool will be a retrospective review of weekend staffing to ensure it meets facility staffing needs as indicated in the facility assessment. The results of this audit will be presented at QAPI and will be the responsibility of the DON/Administrator. The DON/Administrator is responsible for this plan of correction.
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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