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Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: June 17, 2025
Corrected date: N/A
Citation Details **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews during a recertification and abbreviated (Case #s NY 251, NY 678, NY 852, NY 849, NY 370, NY 238, and NY 177, NY 717) survey, the facility did not ensure the provision of sufficient nursing staff to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident throughout the facility. Specifically, (a.) staff reported a lack of sufficient staffing, and (b.) residents reported during interviews that the facility was short-staffed at times, and this resulted in call bells not being answered promptly and long wait times for care to be provided. This is evidenced by: Upon entrance to the facility on [DATE], there were 222 residents residing in six (6) units. The Facility Assessment, last reviewed on 6/02/2025, documented that the facility's bed capacity was 226, with an average daily census of 222 - 225 residents. Section 3.2, titled Staffing Plan, documented the following: - Day shift required 6-11 Licensed Nurses providing direct care, and 12 -23 Certified Nurse Aides. - Evening shift required 6-10 Licensed Nurses providing direct care, and 12 -23 Certified Nurse Aides. - Night shift required 5-7 Licensed Nurses providing direct care, and 6 - 12 Certified Nurse Aides. During an interview on 6/09/2025 at 10:59 AM, Resident #59 stated that staff took long time to answer the call light. They stated it took about an hour for staff to come in, and sometimes staff would just come in and turn the call light off and leave, and they must put it on again. They stated that the second shift also took a long time to come in and assess their needs. During an interview on 6/09/2025 at 11:39 AM, Resident #171 stated that the second shift took a long time to come in. They stated that there was no supervision on the floor at shift change, and staff would not come in tight away or provide an excuse that they just arrived, and they wee unable to provide the care at that time. During an interview on 6/09/2025 at 12:04 PM, Resident #35 stated that only two aides working most of the time and that it was impossible to take care of 40 residents on the unit. They stated that to get out of bed, they required 2 aides and mechanical lift. They stated most of the time, they did not get out of bed because there were not enough staff to assist them. They stated they did not receive full showers or baths due to staffing. During an interview on 6/09/2025 at 3:45 PM, Resident #107 stated that they were always short-staffed and there were not enough staff to take care of all the residents. During an interview on 6/10/2025 at 11:39 AM, Resident #8's family stated that they believed there were not enough staff, and the residents' did not get the care that they required. During a surveyor-led group resident meeting on 6/10/2025 at 11:07 AM, the eight (8) residents in attendance all reported insufficient staffing to meet their needs. They stated that they had often had to wait up to an hour at times for staff to answer their call light. They stated that the staff would turn off their call light and tell them they would be back to provide requested care and never returned. They stated that on the weekends and the 3:00 PM-11:00 PM and 11:00 PM-7:00 AM shifts were the most difficult times. They stated that there had been times when there was one aide by themselves, along with a single nurse. They stated residents' were not getting the care they deserved because they were short-staffed. During an interview on 6/11/2025 at 11:53 AM, Certified Nurse Aide #2 stated they were often short-staffed, and residents would have to wait for care. They stated that there were usually only two aides on the unit, and if they had three, it would be a rare occasion. They stated that there were a lot of individuals on the unit who required added attention, and sometimes they were not able to give them the extra attention that was needed. They stated that there were 6 - 7 residents on the unit that required 2 persons to move, and they had to wait an additional amount of time to provide the care due to the number of staff on the unit at a time. They were able to provide all the needed care, but no time for anything extra. During an interview on 6/11/2025 at 11:53 AM, Certified Nurse Aide #3 stated that there were usually only two aides on the unit most of the time. They further stated that there were a lot of individuals on the unit who required a lot of care, and there was only so much that they could do with the number of staff who were on the unit. They stated that they were able to provide all the needed care, and no resident has gone without care, but there was no time for anything extra, and they would need to wait a little bit longer. During an interview on 6/18/2025 12:09 PM, Licensed Practical Nurse #10 stated that there have been times when they have been short-staffed. Being short-staffed was very stressful and made it difficult completing job functions tasks on time. They stated that there have been times when their medication administrations have been late due to having to assist in the care of residents. During an interview on 6/13/2025 12:32 PM, Registered Nurse #2 stated they often helped by giving medications, toileting residents, and doing dressing changes when the staffing was low, and then stayed late to get their job done. They stated that everyone attempted to pitch in and assist when staffing was low. Many times, other nursing staff came to their unit and assist, as it was one of the larger units in the facility. During an interview on 6/16/2025 at 12:20 PM, Director of Nursing #1 stated they were aware of consistent staffing issues. They stated that staffing was looked at daily and adjusted as needed. They stated that units 2 and 3 were the most demanding units due to the number of residents and their required needs. They stated that they were using multiple incentives to attempt to get additional staffing into the facility. They stated they were not aware of any care not being provided; however, insufficient staffing resulted in residents waiting for care that they should not have to wait for. 10 New York Code Rules and Regulations 415.13(a)(1)(i-iii) | Plan of Correction: ApprovedJuly 27, 2025 F725 ?Çô Sufficient Nursing Staff 1. Corrective Action for Residents Affected: Staffing assignments on Units 2 and 3 were immediately reviewed and adjusted to address resident concerns. The nursing schedule was modified to ensure that staffing levels met the needs outlined in the Facility Assessment. Residents #8, #35, #59, #107, and #171, as well as others identified through a group meeting, were reassessed for unmet care needs or delays. Any concerns found were promptly addressed, and interventions were updated in their care plans. Social Work and the Director of Nursing/Designee met with each of these residents and/or their family members to provide reassurance and review the improvements. Residents confirmed during follow-up interviews that their concerns had been resolved to their satisfaction. 2. Corrective Action for Residents with the Potential to Be Affected: A comprehensive staffing audit was conducted across all units and shifts to ensure adequate coverage. The audit verified alignment with the Facility Assessment and identified areas for redeployment. Social Work interviewed a broader sample of residents to determine if others experienced similar delays or concerns. No additional widespread issues were discovered. To strengthen support, a new Staffing Coordinator was hired, and experienced staff volunteered for additional shifts. Updates to the staffing plan were discussed in Resident Council meetings, and feedback from residents was positive and logged in the resident council minutes. 3. Systemic Measures to Prevent Reoccurrence: A call bell audit tool is now being used by unit managers to track response times weekly. This tool records the activation time, response time, and staff responsible. Monthly reports are compiled and reviewed. All nursing staff were re-educated on call light expectations, shift responsibilities, and respectful resident interactions. Training was conducted on (MONTH) 1, 2025, and included a post-test to confirm comprehension and retention. Recruitment and scheduling teams were educated on strategies to maintain staffing levels, including adjusting schedules, onboarding, and staff incentives. Monthly resident satisfaction surveys will be maintained for 3 months and reviewed in Resident Council meetings. These surveys include specific questions related to the timeliness of care and call light response. 4. Quality Assurance Monitoring: The Director of Human Resources will conduct weekly staffing reviews for one month, then monthly for five additional months. These reviews will compare scheduled coverage with the Facility Assessment to ensure compliance. Call bell audit data and resident satisfaction reports will be presented monthly for 3 months to the Quality Assurance and Performance Improvement committee. If trends show declining performance or gaps in coverage, corrective actions will be implemented immediately. Ongoing monitoring will continue until full compliance is achieved and sustained. Responsible Person: Director of Human Resources / Designee Completion Date: (MONTH) 16, 2025 |