Inadequate Facility Assessment and Staffing Levels
Summary
The facility failed to adequately evaluate their resident population and identify the necessary resources and staffing levels required to provide appropriate care and services. The facility assessment, updated in March 2024, did not accurately reflect the current resident census or the acuity levels across all hallways, particularly omitting information for residents on the 100-200 halls. The assessment indicated an average census range of 50-66 residents, while the actual census was reported to be 87 residents at the time of the survey, with a year-to-date average of 92.9. This discrepancy suggests that the facility did not have an accurate understanding of the resident population, which is critical for determining the appropriate staffing levels and resources needed. Interviews with residents and family members revealed significant delays in response times to call lights, with reports of waiting 20 minutes to an hour for assistance. Family members also noted insufficient staffing, particularly CNAs, which affected the timeliness of care, such as assistance with ADLs and meal service. A CNA expressed concerns about being short-staffed, which impacted their ability to get residents up for meals on time. The Executive Director, who started in August 2024, acknowledged the inaccuracies in the facility assessment and attributed them to a clerical error by the former Administrator. These findings highlight the facility's failure to maintain an accurate and comprehensive assessment of their resident population and resource needs, leading to inadequate staffing and delayed care.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
The facility failed to accurately complete its Facility Assessment, leaving required tables for disease/condition categories, special treatments, and ADL assistance levels blank. The assessment also contained conflicting information, stating that residents requiring ventilator care are not admitted while listing ventilators as available equipment, and identifying amenities such as a gift shop and café/snack bar/bistro for resident use. Additionally, the staffing plan claimed compliance with all state and federal staffing education guidelines, but in-service records showed that no nurse aide met the 12-hour annual in-service requirement. The NHA confirmed the Facility Assessment was not accurately completed.
Surveyors found that the facility’s most recent assessment of its 140-bed operation, including rehab, stepdown medically complex, and LTC dementia/chronic illness units, did not adequately specify how necessary resources are maintained for resident care. The assessment lacked a breakdown of bed capacity per unit and, under its staffing plan, only generally stated that staffing is based on census and acuity and reviewed each shift, with additional RNs scheduled for multiple admissions. It failed to identify contingency planning for non-emergency events that could affect direct care nurse staffing or other care resources, and it did not describe any plan to maximize recruitment and retention of direct care staff, resulting in a deficiency under 10NYCRR S415.26.
The facility’s assessment of needed resources was incomplete, as it only identified staffing levels for census counts at or under 50 and for 63–68 residents in a 24-hour period, with no data for census levels between 51–62 or specific staffing needs by shift. The assessment also lacked a defined plan to maximize recruitment and retention of direct care staff and did not include a contingency staffing plan for non-emergency events that could affect resident care. The NHA acknowledged these gaps and confirmed there was no specific contingent staffing policy, relying instead on staff coming early, staying late, and lead nurses or management filling in on the floor.
Surveyors identified that the facility’s written assessment did not include required elements for staffing recruitment, retention, and contingency planning, despite affecting all 71 residents. The documented assessment omitted a plan to maximize recruitment and retention of direct care staff and did not address how direct care nurse staffing or other care resources would be managed during non-emergency events that could impact resident care. During an interview, the administrator reported having a recruitment plan but confirmed it was not included in the facility assessment and that there was no documented staff retention or non-emergency staffing plan; a requested policy on the facility assessment process was not provided.
The facility did not maintain an accurate and current facility assessment used to determine needed resources for resident care. The assessment listed former key personnel instead of the current NHA, DON, and ADON, contained census information tied only to a prior year-to-date period, and included resident information that had not been reviewed or updated since a previous assessment date. An interim NHA confirmed that the assessment had not been accurately completed and that resident information reflected data from the last time this employee worked at the facility, rather than current conditions.
Surveyors found that the facility failed to maintain an accurate, up-to-date facility-wide assessment reflecting current administrative leadership and necessary emergency medical equipment. The assessment listed various routine medical and non-medical equipment and noted that new admissions using CPAP/BiPAP must supply their own devices, but it did not address emergency medical equipment needed for emergent resident care. The document also lacked evidence of involvement by the current Medical Director, DON, administrator, social worker, or governing body representative, despite facility policy requiring annual review and updates when administrative changes occur.
Inaccurate and Incomplete Facility Assessment Documentation
Penalty
Summary
The facility failed to accurately complete its Facility Assessment as required by regulation. Review of the Facility Assessment Tool dated 4/15/25 showed that the section titled "Disease and Conditions" contained tables intended to document categories of care and the average number of residents receiving special treatments, but these tables were left blank. In the same section, a table to document residents’ levels of assistance with Activities of Daily Living (ADLs) was also left blank. The "Disease and Conditions" section further stated that the facility denies admissions for residents requiring ventilator care, while elsewhere in the assessment conflicting information was documented. In the section titled "Physical Environment and Building/Plant Needs," the facility listed ventilators as a type of physical equipment available for resident care, which conflicted with the statement that residents needing ventilator care are not admitted. This section also listed a gift shop and a café/snack bar/bistro as available for resident use. In the "Staffing Plan" section, the facility documented that it follows all state and federal guidelines for staffing education; however, review of in-service education records showed that no nurse aide met the 12-hour annual in-service requirement. During an interview, the Nursing Home Administrator confirmed that the Facility Assessment had not been accurately completed.
Plan Of Correction
The facility will accurately complete the Facility Assessment to include Review of the Disease and Conditions, Activities of Daily Living that residents require. Physical Environment and Building/Plant. Staffing Plan and in-service education for facility staff. This assessment will be reviewed quarterly and as necessary. Results of this assessment will be presented to the Governing Board of the Greenery Center for Rehab and Nursing quarterly and when changes are made. The Administrator will be educated by the Regional Nurse Consult on completing the required sections of the facility assessment. The Governing Board of the Greenery Center for Rehab and Nursing will monitor this assessment for further compliance with this regulation. Results will be presented at the QAPI committee meeting for review and further recommendations.
Inadequate Facility-Wide Assessment of Resources and Staffing Contingency Planning
Penalty
Summary
The deficiency involves the facility’s failure to conduct and document an adequate facility-wide assessment that determines what resources are necessary to care for residents competently during day-to-day operations and emergencies. During an Abbreviated Survey, record review of the most recent facility assessment, dated on an unspecified date and reviewed by the QAPI Committee on 09/04/2025, showed that the assessment did not sufficiently identify how the facility maintains necessary resources for resident care. The assessment described the facility as a 140-bed SNF with four nursing units (one rehabilitation unit, one stepdown medically complex unit, and two LTC units for residents with dementia and other chronic illnesses), but it did not provide a breakdown of bed capacity per unit. Under the staffing plan section, the assessment stated that staffing is based on resident census and acuity, is reviewed prior to each shift, and that the facility intends to assign the same staff to units and schedule additional RNs for multiple admissions. However, the assessment did not adequately identify contingency planning for events that do not trigger the formal emergency plan but could still affect resident care, such as issues with availability of direct care nurse staffing or other needed resources. Additionally, the assessment did not identify how the facility develops or maintains a plan to maximize recruitment and retention of direct care staff, as required by 10NYCRR S415.26.
Incomplete Facility Assessment and Staffing Plan
Penalty
Summary
The facility failed to maintain a comprehensive facility-wide assessment that identified the resources necessary to care for residents competently during routine operations and emergencies. Review of the facility assessment dated 1/19/26 showed an incomplete staffing plan that only specified the number of staff needed for a census at or under 50 residents in a 24-hour period and for a census of 63–68 residents in a 24-hour period, with no data for census levels between 51–62 residents and no breakdown of specific staffing needs by shift. Further review showed the assessment did not include a plan to maximize recruitment and retention of direct care staff and did not establish a contingency staffing plan for events that do not trigger the facility’s emergency plan but could affect resident care. In an interview, the NHA acknowledged the lack of specific staffing needs by shift and census and confirmed there was no specific contingent staff policy, stating instead that personnel may come early or stay late and that lead nurses or management may help fill in on the floor.
Incomplete Facility Assessment for Staffing Recruitment, Retention, and Contingency Planning
Penalty
Summary
The deficiency involves the facility’s failure to conduct and document a comprehensive facility-wide assessment that included all required components related to staffing resources. The facility assessment dated 12/17/25 did not contain a plan to maximize recruitment and retention of direct care staff, despite this being a required element. The assessment also lacked a contingency plan for situations that did not trigger the formal emergency plan but could still affect resident care, such as issues with the availability of direct care nurse staffing or other care resources. During an interview on 3/13/26 at 3:32 p.m., the administrator acknowledged that while a recruitment plan existed, it was not incorporated into the written facility assessment, and further stated that the assessment did not include a staff retention plan or a plan to address direct care staffing needs outside of the emergency plan. A policy governing how the facility assessment should be conducted and documented was requested by surveyors but was not provided. This failure had the potential to affect all 71 residents in the facility, as the incomplete assessment did not fully address how necessary staffing resources would be ensured during routine operations, nights, weekends, or non-emergency events that could impact resident care.
Failure to Maintain Accurate and Current Facility Assessment
Penalty
Summary
The facility failed to accurately complete and update its facility-wide assessment used to determine necessary resources for competent resident care during routine operations and emergencies. Review of the Facility Assessment dated 3/26/25 showed that the section listing key personnel still identified the previous Nursing Home Administrator, previous Director of Nursing, and previous Assistant Director of Nursing rather than current leadership. The census section referenced a time period of the 2025 year to date without current information, and the section titled “Information about our residents” had not been reviewed or updated since 3/26/25. During an interview on 3/14/26, the Interim Nursing Home Administrator (Employee E12) confirmed that the facility failed to accurately complete the Facility Assessment and that all information about the residents reflected the last time this employee had worked at the facility, rather than current resident data. These findings were cited under 28 Pa. Code 201.18(b)(3)(e)(2) related to management requirements.
Failure to Maintain Current Facility Assessment and Address Emergency Medical Equipment Needs
Penalty
Summary
The deficiency involves the facility’s failure to conduct and maintain an accurate, comprehensive facility-wide assessment that reflects necessary resources, including emergency medical equipment, and current administrative leadership. The facility assessment reviewed on 2/3/2025 listed various medical and non-medical equipment such as Hoyer lifts, sliding boards, transfer devices, grab bars, wheelchair-accessible transportation, feeding tube equipment and bolus services, wheelchairs, specialty cushions, air mattresses, nebulizer and oxygen services, and noted that the facility did not have access to rental CPAP and BiPAP machines, requiring new admissions after 1/1/2024 to provide their own devices and supplies. However, the assessment did not address emergency medical equipment required to meet residents’ emergent medical needs. In addition, the assessment did not show evidence of participation or sign-off by the current Medical Director, Director of Nursing, Administrator, Social Worker, or a representative from the Governing Body. During an interview, the Administrator stated he had been in the position for only a month and had not yet reviewed the facility assessment, despite acknowledging that the assessment must be reviewed at least annually and when there are changes in administrative staff. The Director of Nursing had been in the role since July 2025, yet the assessment had not been updated to reflect the current administrative team. Facility policy on the Governing Body indicated that the Skilled Nursing Administrator is responsible for annual review and ongoing updates of the facility assessment as needed, with data reported to the Governing Body and reviewed through QAPI programs. Despite this policy, the assessment remained outdated and incomplete regarding both administrative staff changes and emergency medical equipment needs at the time of the survey.
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