F0725

E

Persistent Understaffing Below Facility Assessment Par Levels

Bronx, New York Survey Completed on 01-23-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide sufficient nursing staff on a consistent basis to meet residents’ needs as determined by the facility assessment, staffing plan, and residents’ care needs. The facility’s own Facility Assessment, last updated in January 2025, established par levels for LPNs and CNAs on each of five units (Floors 2–6) with a total capacity of 213 beds, including higher-acuity units on the 2nd and 6th floors that required more staff. Despite these defined staffing requirements, review of Payroll Based Journal (PBJ) data for Quarter 4 of 2025 and actual staffing schedules from July 1, 2025 through September 30, 2025 showed that weekend staffing was consistently low and that staffing assignments were frequently below the par levels identified in the Facility Assessment.

The PBJ data and weekend staffing schedules documented repeated shortages of LPNs and CNAs across multiple floors and shifts, particularly on weekends. On numerous Saturdays and Sundays during July, August, and September 2025, there were documented shortages of one LPN on the 3rd, 4th, and 5th floors during the day shift, and at times on the 2nd and 6th floors as well. There were also documented shortages of CNAs on several dates, including on the 2nd, 4th, and 6th floors during day or night shifts. The 6th floor, which was designated for short-term rehab residents with fractures, joint replacements, IV therapy needs, and LTC residents requiring skilled nursing, had a documented requirement of two LPNs on all shifts and five CNAs on the day shift, but this par level was often not met. These documented shortages triggered low weekend staffing in the PBJ report and showed that actual staffing was consistently less than the projected needs in the Facility Assessment.

Interviews with residents and staff further described the impact of these staffing shortages on daily care and services. One resident reported missing therapy sessions because staff were delayed in providing dressing and bathing assistance, stating that aides sometimes did not help them until after breakfast, causing them to be late for rehabilitation therapy and to miss appointments. The same resident stated that staffing was short at night, in the morning, and generally all the time, with people waiting for care and aides being rushed. Another resident reported that there were times when there was only one nurse for an entire floor and that morning medications were sometimes given an hour later than scheduled.

Staff interviews corroborated the pattern of inadequate staffing and its effect on resident care. An LPN stated that the facility had been short of nurses since 2024 and that the 6th floor rehab unit was inadequately staffed, noting that two-person transfers could not be performed timely with only three aides on the day shift when five were required. A CNA reported that the 6th floor was short staffed and that aides were sometimes floated to other units, leaving the 6th floor short; they stated that residents requiring two-person assistance and Hoyer lift transfers sometimes remained in bed and that day showers were pushed to the evening shift. Another CNA stated that even on weekdays the 6th floor often had only four aides for 43 residents and that residents needing Hoyer lift transfers were showered on different days because one aide might be floated to another floor. The staffing coordinator acknowledged awareness of short staffing, especially on day shift and on the higher-acuity 2nd and 6th floors, and stated that call-outs and only partial success in filling shifts contributed to not reaching par levels. The 6th floor RN supervisor and the Director of Nursing both acknowledged that staff from the 6th floor were often floated to other units, and the Administrator confirmed awareness of low weekend staffing and ongoing staffing complaints, stating that the facility could not recruit enough staff to meet the par levels.