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.
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