Incomplete Facility Assessment
Summary
The facility failed to ensure that its facility-wide assessment included all necessary information to allocate resources and care for residents effectively. The assessment, dated 09/12/2024, was missing several critical components, including the name of the governing body representative involved in its completion, a plan for recruiting and retaining adequately trained medical personnel, and a comprehensive list of resources such as supplies and equipment necessary for resident care. Additionally, the assessment lacked an evaluation of contracts and agreements for goods and services, health information technology resources, and an evaluation of the physical environment to meet resident needs. There was also no reference to a facility-based and community-based risk assessment using an all-hazards approach for emergency preparedness. During an interview on 10/03/2024, the Administrator and Administrative Assistant (AA) were questioned about the facility assessment. The Administrator incorrectly identified herself as the governing body, while the AA named an owner of the facility. The AA admitted that portions of the assessment were missing because they did not answer the items appropriately. The AA also stated that the Quality Assurance and Assessment (QAA) committee was responsible for completing the facility assessment, and the Administrator claimed to have reviewed it to ensure all necessary components were in place. However, the deficiencies in the assessment had the potential to affect all 36 residents of the facility.
Penalty
Resources
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The facility failed to include required staffing analyses in its annual facility assessment. The assessment, covering a census of 47 residents, did not document staffing levels or the number and competencies of staff needed to provide necessary care and treatment. It also lacked consideration of specific staffing needs for each resident unit and each shift, and did not address how staffing would be adjusted based on changes in the resident population. The Administrator confirmed that the assessment did not contain the required staffing information.
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.
Failure to Include Required Staffing Analysis in Facility Assessment
Penalty
Summary
The deficiency involves the facility’s failure to include required staffing assessments in its annual facility-wide assessment. The facility assessment, updated in March 2026, did not document staffing levels needed to ensure there were a sufficient number of staff with appropriate competencies and skill sets to provide the necessary care and treatment for the resident population. The assessment lacked information on how staffing needs were determined based on the care required by the 47 residents in the facility, as required by the regulation. The assessment also did not contain any documented consideration of specific staffing needs for each resident unit or how staffing would be adjusted based on changes in the resident population. In addition, there was no documentation addressing specific staffing needs for each shift (day, evening, night) in relation to changes in resident acuity or population. During an interview, the Administrator confirmed that the facility assessment did not contain the required information regarding specific staffing required for the resident population.
Plan Of Correction
F838 Facility assessment The building administrator has completed a facility-wide assessment as of 4-9-2026 and determined the resources necessary to care for its residents completely during day-to-day operations, including nights weekends and emergencies. Also including staffing numbers and staff with appropriate competencies and skill. The administrator was in serviced the expectations of what is included in the Facility 3-17-26 by corporate nurse. This could affect 47 out of 47 residents. Sweep of the residents completed 3-28-2026 by management team didn't reveal any negative outcomes as a result of this practice. The administrator will audit for the changes needed in the facility assessment monthly, to begin 4-9-2026. The facility assessment will be submitted to the monthly QAPI for approval. and monitored in quarterly QAPI
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.
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