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F0725
E

Failure to Maintain Minimum Nursing Staff Levels

Brewster, New York Survey Completed on 04-23-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide sufficient nursing staff to meet the needs of all residents, as evidenced by multiple occasions where staffing levels fell below the facility's own minimum guidelines across several shifts and units. Record reviews of staffing schedules for February, March, and April 2025 revealed repeated instances where the number of Certified Nurse Aides (CNAs) on duty was less than required for both day, evening, and night shifts. The facility's staffing plan outlined specific minimums, but these were not consistently met, resulting in periods where only two CNAs were present on units that required three, and similar shortfalls on other shifts. Interviews with CNAs and nursing staff confirmed that these staffing shortages led to delays in resident care, such as longer wait times for toileting, feeding, and showers. Staff reported being unable to complete all scheduled showers and having to postpone care tasks to later shifts or days. CNAs described increased workloads, with some responsible for up to 20 residents each, and noted that residents and their families frequently complained about the delays in care. Staff also reported that the lack of adequate staffing contributed to issues such as increased urinary tract infections and skin breakdowns due to delayed incontinence care. The staffing coordinator and DON acknowledged the ongoing challenges in maintaining adequate staffing, despite efforts to use agency staff and incentive programs. Staff interviews indicated that the use of agency staff did not always resolve the issue, and regular staff were often asked to work extra shifts, leading to physical exhaustion. The administrator, newly in position, stated they were working to improve staffing numbers. The deficiency was cited under 10NYCRR 415.13(a)(1)(i-iii) for failing to ensure sufficient nursing staff to meet resident needs.

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