F0725

E

Ongoing Insufficient Nursing and RN Coverage Leading to Unmet Resident Care Needs

Flushing, New York Survey Completed on 02-05-2026

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 and to have a licensed nurse in charge on each shift, as required by its own facility assessment and staffing plans. The facility assessment documented a bed capacity of 143 residents with an average daily census of 134, most of whom had reduced physical function, behavioral health needs, and required assistance of one to two staff for activities of daily living. Based on this acuity, the assessment identified a need for 17 licensed nurses providing direct care and 36 CNAs at any given time, and the general staffing plans called for specific CNA coverage on each shift for Units 1, 2, and 3.

Despite these identified needs, review of Payroll Based Journal data and actual staffing schedules from July 2025 through early February 2026 showed repeatedly low weekend staffing and documented shortages of both licensed nurses and CNAs. On multiple dates, the number of CNAs who actually worked was significantly lower than the number scheduled, including instances where only one CNA worked a night shift on a unit with 44 residents, and where only two CNAs worked evening shifts on units with census counts in the low 40s despite higher scheduled numbers. On numerous weekend and day shifts across several months, there were no RNs working on Units 1, 2, and 3 even though two or three RNs had been scheduled, resulting in shifts without the RN coverage that the facility’s own plans required.

Resident reports and staff interviews further substantiated the ongoing staffing deficiencies. During a Resident Council meeting, several residents stated that the facility was short staffed on every shift, reporting that totally dependent residents were often not changed until the next day, that at times there was no staff available to answer phone calls or questions when the nurse was busy passing medications, and that staffing had been so poor in recent months that some residents did not receive showers for several days. The Staffing Coordinator and the DON both acknowledged awareness of low nursing staffing since the previous year, attributing it in part to last-minute call-outs that were difficult to replace. The Administrator also acknowledged that having sufficient nursing staff was a challenge. These observations, records, and interviews collectively demonstrate that the facility did not consistently meet its assessed minimum staffing levels or ensure a licensed nurse in charge on each shift, resulting in unmet resident care needs.