F0725

E

Insufficient Nursing Staff Leading to Delayed Care, Missed ADLs, and Untimely Nursing Tasks

Rochester, New York Survey Completed on 03-18-2026

Penalty

No penalty information released

Summary

The deficiency involves the facility’s failure to provide sufficient nursing staff on all units to meet residents’ daily needs for ADL care, toileting, incontinence care, grooming, bathing, supervision, and timely nursing tasks. The facility assessment showed a licensed capacity of 147 beds with an average daily census of 136 residents and a staffing plan that called for two LPN medication nurses and four CNAs per unit on day and evening shifts, and one LPN and two CNAs per unit on night shift, plus additional RN/LPN managers and supervisors. Review of staffing records and timecards from early February through mid-March revealed repeated discrepancies between scheduled and actual staffing, including missing time punches and staffing levels below the facility’s stated plan. On multiple dates, units operated with fewer CNAs than planned, including days when only two CNAs were assigned to a 34-resident dementia unit and nights when listed CNAs and a nurse had no documented punches. A facility list showed that 50% of CNAs employed over a roughly three‑month period were no longer employed.

On the second floor, with a census of 24 residents, the nurse manager reported staffing of one nurse manager, two LPNs, and two CNAs on day shift. A resident reported waiting four hours for a bedpan after activating the call light early in the morning, ultimately soiling themselves and not receiving assistance until therapy staff arrived. Another resident stated they were told they would have to wait to get out of bed due to lack of staff, and a visitor reported the unit was often staffed with only one CNA and one nurse, especially on Mondays and weekends. On the third floor, with 37 residents, there was a strong urine odor in a hallway, and residents reported that nothing was on time, including meals and medications. Observations showed a resident in bed in a hospital gown with a breakfast tray still in front of them late in the morning, and other residents with several days of facial hair growth, greasy and unwashed hair, and reports of missed showers, including one resident who stated they had not received a shower for two months and that the facility was short staffed.

On the fourth floor, with 36 residents, day shift staffing consisted of two nurses and two CNAs. A resident reported waiting up to an hour for toileting assistance and said staff expressed frustration when the resident was incontinent. A strong urine odor was noted in the hallway, and another resident stated call light response times were hours due to short staffing, that at times only one CNA was available for the entire floor, and that staff told them to wait until the next shift for care. On the fifth floor dementia unit, with 34 residents, observations showed multiple residents in the dining room in pajamas or hospital gowns with a strong urine odor throughout the unit. Staffing at one point included two LPNs, one CNA, and an RN manager working as a CNA. Residents were observed with uncombed hair, unchanged appearance over several hours, stained pajamas with fecal odor, and visible fecal matter under fingernails while later eating without hand hygiene. Staff interviews on this unit described being unable to complete rounds and incontinence checks before meals, missed showers, delayed toileting and two‑person transfers, and late medications due to staffing shortages.

Additional interviews across the facility reinforced that staffing levels were frequently below target and insufficient to meet resident needs. A special Resident Council meeting revealed residents waited two to three hours for care, staff worked in multiple roles due to shortages, residents were not always assisted out of bed and therefore missed activities, and weekend staffing was described as the worst. A CNA stated there was never enough staff, sometimes only one CNA was available, residents required full bed changes at the start of shift, showers were missed, and staff had to leave their own assignments to assist with two‑person transfers. An LPN reported being called to assist in the kitchen, which delayed medication administration, and another LPN stated that tasks such as checking medication carts for loose or unlabeled pills were not completed because higher priority care needs took precedence under staffing shortages. The staffing coordinator acknowledged the facility frequently operated below target staffing levels, often with only two to three CNAs per unit on day and evening shifts and one CNA on nights, and admitted these levels were not sufficient to meet resident needs and that they did not know how to resolve the staffing issues. Leadership interviews confirmed that staffing had not been a focus of the QAPI committee, and the DON acknowledged that current staffing was not ideal and was affected by call‑offs, requiring staff to work in multiple roles.