F0725

F

Persistent Understaffing of Nursing and Support Staff

Rensselaer, New York Survey Completed on 02-25-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide sufficient nursing staff, including licensed nurses and CNAs, to meet residents’ needs as outlined in its own facility assessment. The assessment dated January 2026 specified required nursing administration and direct-care staffing per unit and per shift, including RN/LPN supervisory coverage and minimum CNA numbers on days, evenings, and nights. Review of staffing sheets from late November 2025 through late February 2026 showed repeated and sometimes severe understaffing compared to these minimums, including multiple shifts with fewer nurses and CNAs than required and numerous night shifts with no scheduled nurses or no CNAs. On several dates, there were zero nurses scheduled for the night shift aside from a nurse supervisor, and on some nights there were no CNAs scheduled at all.

Residents reported that this staffing pattern affected their care. One resident stated staffing was an issue, turnover was very high, and they were sometimes scared to ask for pain medication because staff were so busy; this resident reported receiving only one shower per week and feeling that staff became upset if they asked for more assistance. Another resident described being suspicious of staff and believed the facility was short staffed, reporting that getting help to clean up was inconsistent and that they sometimes had to wait a long time for pain medication. A different resident reported that staffing was too often short, especially at night, and described waking up in the morning with the bed soaked from overnight because no one had been available to change them; this resident stated they would ring the call bell when needing the bathroom or incontinence care, but no one would come, and that call bells often took 30 minutes or more to be answered, particularly on nights.

Additional residents and staff corroborated ongoing staffing shortages. Several residents stated there were not enough staff, particularly on the overnight shift, and that medications were not always given on time and they had to wait a long time for help. A CNA reported that it was difficult to get to all residents on their assignment, especially on the 3 PM–11 PM shift when some residents became more confused, and that they often had to complete documentation an hour after their shift ended due to workload. The staffing coordinator, who assumed responsibility for staffing in mid-February 2026, acknowledged that staffing levels were based on the facility assessment and that call-outs and no-call/no-shows disrupted staffing. An LPN described typical patterns of having fewer aides than expected on days and evenings and only one aide per floor and one LPN for both floors at night, with situations where the supervisor was the only LPN and had to perform both medication passes and supervisory duties. Dietary staff and the ombudsman also reported inconsistent staffing, including an instance when breakfast was delayed until late morning and prepared by maintenance because kitchen staff had called out.