Deficient Facility Assessment Lacks Required Involvement and Staffing Plans
Summary
The facility failed to ensure its Facility Assessment was developed in accordance with federal requirements. Specifically, the assessment did not demonstrate the active involvement of required individuals, including direct care staff, direct care representatives, residents, resident representatives, and family members. This omission was confirmed during an interview with the Administrator, who acknowledged that these groups were not actively involved in the development of the Facility Assessment. Additionally, the Facility Assessment did not address the resources necessary to care for residents during weekends, nor did it include a plan to maximize recruitment and retention of direct care staff. The assessment also lacked a contingency plan for staffing needs in situations that do not require activation of the facility's emergency plan. These deficiencies were identified through a review of the facility's documentation and were verified by the Administrator. The Administrator further confirmed that the Facility Assessment had not been updated to reflect the latest CMS guidance, which requires these elements to be included. The lack of comprehensive identification and addressing of the resident population's needs and available resources had the potential to result in unmet care needs for residents.
Plan Of Correction
How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. On 6/24/25, administrator completed the most current version of the Facility Assessment. The assessment was brought to the QA committee for discussion and approval on 6/25/25. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. All residents have potential to be affected by the deficient practice. The administrator will continue to gather feedback from emergency drills, monthly safety meetings, monthly all-staff meetings, and monthly QA for feedback on communication protocol and any necessary changes to Facility assessment and Emergency Operations Plan in the event of an emergency. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur. Administrator will verify the most recent version of the facility assessment prior to creating the Facility Assessment for 2026 and upcoming years. How the facility plans to monitor its performance to make sure that solutions are sustained. Facility Assessment will be discussed at the monthly QA meeting for feedback from floor staff and department heads to review findings from monthly safety committee/all-staff meetings and learnings from disaster/fire/emergency drills. Date of compliance: 6/25/25
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
The facility did not update its facility-wide assessment as resident acuity increased, resulting in an inaccurate determination of needed licensed nursing staff. The written assessment specified one RN for one day shift per week and projected a need for 10 LPNs across 24 hours, with detailed LPN coverage by shift, and stated it should be reviewed and updated as needed to guide staffing decisions. At the time of survey, the DON reported 36 residents in the facility, acknowledged that resident acuity was higher than when the assessment was completed, and stated that the actual pattern was two LPNs on the floor for the day shift and two LPNs for the night shift, with the DON, ADON, and MDS coordinator available only during weekday business hours. The DON identified a total of seven licensed staff available and stated that more staff were needed to work directly with residents, confirming that the facility assessment no longer reflected current resident needs or staffing resources.
The facility failed to complete an accurate, building-specific facility assessment to determine needed resources and staffing for its resident population, including many residents with dementia or cognitive impairment. The written assessment left the behavioral and cognitive acuity fields blank, did not describe how supervision needs for cognitively impaired residents would be met, and contained generic staffing ratios that did not account for 12‑hour shifts or explain how staffing levels were determined for each unit. Leadership interviews revealed that about half of the residents had dementia or cognitive impairment, there was no formal acuity measure in use, and nursing staff levels were insufficient to meet supervision needs, with reports that residents were getting hurt. The DSD, interim DON, and administrator all acknowledged that the assessment did not clearly address dementia care, supervision requirements, or a method to determine acuity for staffing.
The facility’s assessment failed to include required competencies for Activities staff assigned as smoking monitors. Activities personnel, including a Recreation Transporter, were responsible for assessing residents’ smoking practices and monitoring residents during smoking, including those on oxygen, but the facility-wide assessment did not specify the knowledge, training, or skills needed for safe smoking monitoring and oxygen safety. Although the Administrator reported that new smoking monitors receive training and are evaluated by demonstration, and that smoking was listed as a special care need in the assessment, the document did not detail the actual training requirements for this role, leading to a deficiency related to incomplete evaluation of staff competencies.
Surveyors found that the facility’s required assessment of resources did not include its secured dementia unit or the building’s wander guard system, despite the presence of a locked, camera-monitored unit with coded entry/exit doors and a capacity of 35 residents. Documentation showed criteria for admission to the secured dementia unit based on dementia diagnoses and wandering or elopement behaviors, and the assessment identified numerous residents with dementia, impaired cognition, and behavioral health needs, with staff trained in dementia care. However, the physical environment section of the assessment omitted any reference to the secure unit or wander guard system, which the Administrator later acknowledged as an oversight.
Facility Assessment did not match actual night shift staffing. The assessment stated Harmony Manor and Quail Corner each required an LPN on nights, with consistent staffing prioritized in the memory care unit, but the April schedule showed both units sharing one licensed nurse on multiple nights. The DON confirmed one nurse was responsible for all 32 residents on those nights and acknowledged the assessment needed to reflect the staffing schedule.
Surveyors found that the facility’s 2026 facility-wide assessment, completed with a census of 69 residents, listed only total full-time employees and did not evaluate resident acuity or define specific staffing needs for each shift for RNs, LPNs, MA-Cs, and CNAs. In an interview, the administrator acknowledged that the assessment did not include shift-specific staffing requirements and stated he believed the assessment met regulatory requirements.
Failure to Update Facility Assessment to Reflect Increased Resident Acuity and Staffing Needs
Penalty
Summary
The facility failed to update its facility-wide assessment as resident acuity increased, resulting in an inaccurate determination of needed nursing resources. The written facility assessment dated 10/15/25 stated that one RN was needed for one day shift per week, including weekends, and projected a total of 10 LPNs needed to provide care in a 24-hour period. The assessment further specified that seven LPNs were needed for the day shift, five for the evening shift, and four for the night shift. The assessment document itself stated that it was to be reviewed annually and updated as needed, and that it was to be used to evaluate the resident population and determine the resources necessary to care for residents competently during day-to-day operations and emergencies, and to drive staffing decisions. At the time of the survey, the DON identified that 36 residents resided in the facility and reported that the acuity level of the residents was higher than it had been in October 2025 when the facility assessment was completed. The DON stated that the projected need for ten LPNs in a 24-hour period was not correct and described the actual staffing pattern as two LPNs working on the floor from 7 a.m. to 7 p.m. and two LPNs working on the floor from 7 p.m. to 7 a.m., with the DON (RN), assistant DON (RN), and MDS coordinator (LPN) available to assist with resident needs during business hours, five days a week. The DON counted a total of seven licensed staff members available and acknowledged that more staff were needed to work directly with residents given the current higher acuity, demonstrating that the facility assessment had not been updated to reflect the current resident population and resource needs.
Failure to Conduct Accurate Facility Assessment for Dementia Care and Staffing Acuity
Penalty
Summary
The deficiency involves the facility’s failure to conduct and document a comprehensive facility-wide assessment that accurately reflected the needs of its resident population, particularly residents with dementia or cognitive impairment, and the resources required to care for them. The written facility assessment dated 10/15/25 acknowledged that the facility accepted residents with Alzheimer’s disease and dementia and referenced behavioral symptoms and cognitive performance in its acuity table, but the corresponding number/average range of residents was left blank. Although the assessment’s services section referenced mental health and behavior needs, including care of individuals with cognitive impairment, it did not identify how the facility would meet the supervision needs of these residents. The assessment’s staffing plan section listed generic staffing numbers and ratios for licensed nurses (RN, LVN) and nurse aides (CNA, RNA), but it did not explain how these numbers were determined, did not reflect that nursing staff worked 12‑hour shifts, and did not describe a method for determining resident acuity to support sufficient staffing. The tables contained placeholders such as “1:x LN ratio” and “1:x ratio days/evenings/nights” without clear, building‑specific calculations or justification. The assessment also failed to describe how individual staff assignments were determined and reviewed to ensure coordination and continuity of care across units, and it did not specify the staffing needs on each resident unit for residents requiring increased supervision. Interviews with facility leadership confirmed that the written assessment did not match actual resident needs or staffing practices. At the time of survey, the census was 73 residents, with 27 residents documented as having a dementia diagnosis. The DSD, who was covering staffing, stated that approximately half of the residents had dementia or cognitive impairment and required more supervision, that there was no measure of resident acuity being done, and that the facility lacked sufficient nursing staff to meet supervision needs, resulting in residents getting hurt. The DSD further stated that the staffing numbers in the assessment were not personalized to the building, were inaccurate, and that she did not understand their origin. The interim DON and the administrator both acknowledged that staffing was a problem, that resident acuity should have been assessed and clearly reflected in the facility assessment, and that the assessment should have identified and assessed resident supervision needs, which had not occurred.
Failure to Include Smoking Monitor Competencies in Facility-Wide Assessment
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment that evaluated staff competencies necessary to meet resident needs, as required by regulation. Surveyors found that the facility’s assessment, dated 09/2025, did not include the specific knowledge, training, and skills required for Activity Aides who were assigned to monitor residents who smoke. Although the facility’s policy and assessment referenced identifying resident acuity levels, providing continuous care through consistency, and basing staffing plans on resident population and needs, the assessment did not address competencies related to safe smoking monitoring and oxygen safety for the Activities staff who were functioning as smoking monitors. During the abbreviated survey, it was determined that one of four smoking monitors lacked documented evaluation of competencies necessary to provide the level and type of care needed for residents who smoke. The facility had designated Activities staff, including a Recreation Transporter, to assess residents’ smoking practices and to monitor residents during smoking activities, including residents using oxygen. In an interview, the Administrator stated that newly hired smoking monitor staff receive specific training and are evaluated by demonstration on proper monitoring of residents in the smoking room and residents with oxygen, and that noncompliant resident smoking behavior prompts ongoing staff re-education. The Administrator also stated that smoking was identified as a special care need in the facility assessment and referenced under other special needs and services related to buildings, but acknowledged that the assessment did not elaborate on the actual training required for safe smoking monitoring, resulting in a deficient facility assessment under 10 NYCRR 415.5(h)(2).
Failure to Include Secured Dementia Unit and Wander Guard System in Facility Assessment
Penalty
Summary
The deficiency involves the facility’s failure to include its secured dementia unit and associated wander management system in the required facility-wide assessment of resources needed to care for residents during routine operations and emergencies. Surveyors observed over multiple days that the building contained a secured unit on the right side of the facility, accessible only by doors requiring numeric codes to enter or exit, with additional coded exits leading to an internal courtyard and the exterior rear of the building, as well as a vestibule with coded doors and an interior entrance button. The unit had three hallways with cameras feeding to a monitor at the secured unit nurses’ station and a capacity of 35 residents. Sensors for a wander guard system were observed throughout the building, including near exit doors, and the system was confirmed to be operational. Review of facility documentation showed that the facility had established criteria for admission to a secured dementia unit, requiring a dementia diagnosis and behaviors such as elopement or wandering that necessitated closer supervision. The facility assessment identified 130 licensed beds and common diagnoses including Alzheimer’s disease, non-Alzheimer’s dementia, impaired cognition, and other behaviors requiring intervention, with an average of 36 residents having behavioral symptoms and cognitive performance issues and 36 residents receiving special treatments for behavioral health needs. The assessment also stated that all staff receive competency training on caring for residents with dementia, Alzheimer’s disease, and cognitive impairments. However, in the section addressing physical environment and building/plant needs, the assessment did not identify the wander guard system or the existence of the secure unit. In an interview, the Administrator confirmed there was a secured dementia unit policy, acknowledged that the secure unit was not included in the facility assessment and stated this was an oversight, and also confirmed the facility’s capacity as 120 beds.
Facility Assessment Did Not Match Night Shift Staffing
Penalty
Summary
The facility failed to ensure its Facility Assessment accurately reflected current staffing needs. The Facility Assessment, updated 03/26/2026, stated the staffing plan included one licensed nurse on night shift for Harmony Manor and one licensed nurse on night shift for Quail Corner, and that consistent staffing would be prioritized in the memory care unit, with staffing levels not adjusted for low census or low acuity so resident needs would be met during call-ins and other staffing shortages. However, the April 2026 staffing schedule showed Quail Corner and Harmony Manor sharing a licensed nurse during night shift on multiple nights. During an interview on 04/24/2026, the DON stated that on Saturday, Sunday, Monday, and Tuesday nights, both units shared one licensed nurse during night shift, and that the nurse was responsible for all 32 residents in the facility. The DON confirmed the Facility Assessment indicated each unit required a licensed nurse during night shift and stated the Facility Assessment needed to be updated to reflect the staffing schedule.
Failure to Include Shift-Specific Staffing and Acuity in Facility Assessment
Penalty
Summary
The deficiency involves the facility’s failure to conduct and document a comprehensive facility-wide assessment that considered specific staffing needs for each shift in order to care for residents competently during routine operations and emergencies. The facility assessment dated 1/5/26 for the 2026 year, with a census of 69 residents, listed only the total number of full-time employees and did not include an evaluation of resident acuity or delineate required staffing levels by shift (day, evening, night) for RNs, LPNs, MA-Cs, and CNAs. During an interview on 4/22/26 at 3:40 PM, the administrator confirmed that specific staffing needs by shift were not included in the assessment and stated that he believed he had completed the facility assessment in accordance with requirements. No additional resident-specific clinical details or medical histories were provided in the report, and the findings focus solely on the omission of shift-specific staffing analysis and resident acuity considerations in the facility’s assessment documentation.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release August 26, 2026) and official state health department websites — never guesswork.
In your survey window? See what surveyors are citing.
The Survey-Prep Report maps your facility's risk from 12 months of CMS and state citation data — what's being cited around you and what to check first. $129 one-time.