Insufficient Nursing Staff Leading to Delayed Call Bell Response and Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet residents' needs and to ensure resident safety and the attainment or maintenance of each resident's highest practicable well-being. Residents reported during interviews that the facility was short-staffed at times, which resulted in call bells not being answered promptly and long wait times for care. The facility’s own Facility Assessment, dated 07/2025, specified desired staffing levels for the 2nd floor rehabilitation unit and the 3rd and 4th floors, including specific numbers of CNAs and LPNs for day, evening, and night shifts. Review of facility staffing sheets for multiple dates in March 2026 showed repeated deviations from these desired staffing levels across several units and shifts. On numerous dates, the 2nd floor rehabilitation unit had only two CNAs on night shift instead of the three specified, and the 3rd and 4th floors frequently operated with fewer CNAs and/or LPNs than outlined in the Facility Assessment for day, evening, and night shifts. Examples included shifts with only one LPN where two were specified, and shifts with reduced CNA coverage, including some night shifts with only one CNA. On at least one occasion, the night nursing supervisor had to cover as a floor nurse with only one CNA on the night shift. These documented staffing levels, combined with resident reports of delayed call bell response and long waits for care, formed the basis of the deficiency under 10 NYCRR 415.12(h)(1)(2).
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