Failure to Include Ethnic and Language Factors in Facility Assessment
Summary
The facility failed to ensure that their facility-wide assessment included a detailed review of the ethnic, cultural, and language factors of their resident population, specifically the Cuban population. This deficiency was identified during a review of the facility's policy and assessment documents. The policy, revised on 01/25/2024, mandates an annual facility assessment to determine the capacity to meet residents' needs, including religious, ethnic, and cultural factors that affect care delivery. However, the assessment dated 01/18/2024 did not identify any residents of Cuban descent, Spanish as a preferred language, or the need for an interpreter. Resident #61, who was admitted with diagnoses including Coronary Artery Disease, Hypertension, and Diabetes Mellitus, was identified as Cuban with a preferred language of Spanish. This information was confirmed by the facility's Administrator during a review on 05/08/2024. The Administrator acknowledged that the facility's assessment failed to include the necessary ethnic, cultural, and language considerations for Resident #61, thereby affecting the delivery of his care.
Penalty
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The facility did not complete a comprehensive facility-wide assessment to determine necessary resources for competent resident care during day-to-day operations and emergencies. The assessment lacked information on the resident population, including the number of residents, facility capacity, and care needs related to behavioral health, cognitive disabilities, and overall acuity. It also failed to address direct care staff such as RNs, LPNs, and CNAs, and did not document the total number of staff needed to ensure sufficient qualified personnel to meet residents’ assessed needs. Leadership confirmed that the assessment was missing required elements, and this issue was identified incidentally during a complaint investigation.
The facility’s written assessment of its staffing needs did not accurately reflect the number of staff required to meet resident care needs. The assessment, based on an average daily census of 83 residents including a locked memory care unit, listed estimated numbers of licensed nurses and nurse aides needed for direct care. However, the Regional Administrator later confirmed that administrative nurses (such as the DON, ADON, and MDS nurse) had been incorrectly counted as direct-care licensed staff, and administrative personnel (such as admissions and medical records staff) had been counted as nurse aides. This resulted in an inaccurate facility-wide assessment of the staffing resources necessary to meet residents’ assessed needs and care plans.
Surveyors found that the facility’s written assessment of its capabilities and resources was inaccurate, particularly regarding respiratory services and staffing. The assessment listed specific numbers for oxygen therapy, suctioning, tracheostomy care, and ventilator care but did not include staffing needs for residents receiving respiratory services and indicated no tracheostomy care and capacity for only two ventilator residents. An RT reported that there were actually two residents with tracheostomies and two on ventilators, and the Administrator acknowledged that the assessment reflected average resident numbers rather than the number of residents the facility could care for, stating the facility could admit up to ten ventilator residents and that no specific staffing requirements were documented for ventilator or trach care.
A facility-wide assessment failed to accurately account for the number of residents dependent on staff for ADLs such as toileting, dressing, bathing, and transferring, resulting in staffing levels that did not meet the actual needs of the resident population. Interviews with the DON, Administrator, and Dietary Director confirmed that both direct care and dietary staffing were insufficient compared to the requirements outlined in the assessment, leading to inadequate care coverage during both routine operations and emergencies.
The facility did not update its facility-wide assessment as required, with documentation showing the last update occurred over two years ago. The Administrator confirmed no evidence of an updated assessment, potentially affecting all residents.
The facility did not accurately assess or document the presence of residents with psychiatric or mood disorder diagnoses in its facility-wide assessment, despite staff confirming that multiple residents had such conditions. The assessment also failed to identify the need for behavioral health services, resulting in a mismatch between documented resources and actual resident needs.
Incomplete Facility-Wide Assessment of Resident and Staffing Needs
Penalty
Summary
The facility failed to complete a comprehensive facility-wide assessment to determine the resources necessary to care for residents competently during routine operations and emergencies. Review of the facility assessment dated 01/30/26, completed by the administrator, showed it did not address the resident population, including the number of residents, the facility’s capacity, or the care required based on behavioral health needs, cognitive disabilities, and overall acuity. Further review showed the assessment did not address direct care staff such as RNs, LPNs, and CNAs, and did not document the overall number of facility staff needed to ensure a sufficient number of qualified staff to meet each resident’s needs as identified through assessments and care plans. During an interview, the regional director of clinical operations and the administrator confirmed that the facility assessment was not completed with all required elements. This deficiency was identified as an incidental finding during the course of a complaint investigation, and the facility census at the time was 65 residents.
Inaccurate Facility Assessment of Staffing Needs
Penalty
Summary
The facility failed to accurately complete its facility-wide assessment regarding the number of staff needed to provide competent care to all residents during routine operations and emergencies. The written Facility Assessment Tool, updated 02/13/26, documented an average daily census of 83 residents, including a locked memory care unit with a 32-bed capacity and an average daily census of 28. The assessment identified a wide range of care needs for the memory care unit, including ADLs, mobility and fall risk, bowel and bladder care, skin integrity, mental health and behavioral needs, medications, pain management, infection prevention and control, management of medical conditions, therapy, nutrition, and person-centered psycho/social/spiritual support. The facility’s assessment stated it estimated needing 12–14 licensed nursing staff to provide direct care, 20–25 nurse aides, and three nursing personnel with administrative duties to care for the resident population. During an interview, the Regional Administrator confirmed that the staffing estimates documented on the Facility Assessment were incorrect. She explained that, when determining the number of licensed nurses providing direct care, she had inappropriately included administrative nurses such as the DON, ADON, and MDS nurse. Similarly, when calculating the number of nurse aides, she had included individuals in administrative roles, such as admissions and medical records staff. As a result, the facility assessment did not accurately reflect the overall number of facility staff actually needed to ensure a sufficient number of qualified staff were available to meet each resident’s needs as identified through resident assessments and care plans. This deficiency was identified as an incidental finding during the investigation of Master Complaint Number 2746972.
Inaccurate Facility Assessment of Respiratory Care Capacity and Staffing
Penalty
Summary
The deficiency involves the facility’s failure to complete an accurate facility-wide assessment of the resources needed to care for residents, including during day-to-day operations and emergencies. The written facility assessment stated that the facility treats a wide range of patients transitioning from hospital to home and that, prior to admission, the DON and interdisciplinary team assess residents’ physical and psychosocial needs to determine appropriate placement. The assessment also indicated that special treatments available in the facility included respiratory services such as oxygen therapy, suctioning, tracheostomy care, and ventilator or respirator care, and it listed specific numbers for these services (oxygen therapy 15, suctioning 5, tracheostomy care 0, ventilator/respirator care 2). However, the assessment did not include information on staffing needs for residents receiving respiratory services. During an interview, an RT reported that there were two residents with a tracheostomy and two residents with ventilators in the facility, which did not match the facility assessment’s indication of zero tracheostomy care and capacity for only two ventilator/respirator residents. In a separate interview, the Administrator stated that, in the facility assessment, they had entered the average number of residents usually present with certain care needs rather than the number of residents the facility was able to care for based on those needs. The Administrator further stated that the facility was able to admit ten residents with ventilators, confirming that the assessment was not based on the services the facility could provide and that there was no specific number or types of staffing requirements listed to address the needs of residents on ventilators or receiving tracheostomy services. This inaccuracy had the potential to affect all 49 residents in the facility.
Inaccurate Facility Assessment Leads to Inadequate Staffing for Resident Care
Penalty
Summary
The facility failed to conduct an accurate and thorough facility-wide assessment to determine the necessary resources required to care for residents competently during both routine operations and emergencies, including nights and weekends. Review of resident data revealed that the number of residents dependent on staff for activities of daily living (ADLs) such as toileting, dressing, bathing, and transferring significantly exceeded the facility's stated capacity in its assessment. Specifically, there were 15 residents dependent on staff for toileting, 14 for dressing, 14 for bathing, and 9 for transferring, while the facility assessment only accounted for the ability to care for five residents in each of these categories. Additionally, the assessment outlined staffing requirements that were not met, including the need for four full-time RNs, four full-time LPNs, and fourteen full-time CNAs, while actual staffing levels were lower in several categories. Interviews with the Director of Nursing (DON), Facility Administrator, and Dietary Director confirmed discrepancies between the facility assessment and actual staffing levels, including insufficient numbers of direct care and dietary staff to meet the needs of the current resident population. The DON and Facility Administrator acknowledged that the facility-wide assessment was not completed accurately, resulting in inadequate staffing to provide timely and quality care for residents. This deficiency was identified during a complaint investigation and had the potential to affect all residents in the facility.
Failure to Update Facility Assessment Annually
Penalty
Summary
The facility failed to update its facility-wide assessment annually as required. Review of the assessment showed it was last dated over two years prior to the survey, and the Administrator confirmed during interview that the date had not been changed and could not provide evidence of any updates since that time. This lapse had the potential to affect all 75 residents in the facility. The deficiency was identified during a complaint investigation and was based on both document review and staff interview.
Failure to Assess and Document Behavioral Health Needs in Facility Assessment
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment to accurately determine the resources necessary to care for its resident population, specifically neglecting to identify and evaluate residents with psychiatric and/or mood disorder diagnoses. Record review showed that the facility assessment did not list any residents with such diagnoses, and staffing was marked as adequate for dementia and mental health conditions, with behavioral health services noted as not applicable. However, staff interviews confirmed that 37 residents residing in the facility at the time had psychiatric and/or mood disorder diagnoses, indicating a significant discrepancy between the documented assessment and the actual needs of the resident population.
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