Incomplete Facility-Wide Assessment
Summary
The facility failed to conduct and implement a comprehensive facility-wide assessment that included the necessary resources to provide both emergency and day-to-day care for its resident population. The assessment was not updated to meet the new requirements specified in the Centers for Medicare and Medicaid Services Quality Safety Oversight Memorandum (QSO-24-13-NH), which became effective in August 2024. The facility's assessment lacked critical information about the resident population, such as diseases, conditions, and cognitive limitations, which are essential for determining staffing needs and competencies. The facility assessment tool, last updated in December 2023 and reviewed with the Quality Assurance Performance Improvement (QAPI) committee in June 2024, was incomplete. Key sections, including those related to resident profiles, staff competencies, and facility resources, were left blank. The assessment did not involve active participation from key individuals such as direct care staff, residents, and families, as required by the new guidance. The Administrator and Director of Nurses (DON) were the only individuals involved in creating the assessment, and they acknowledged the missing information during interviews with the surveyor. Additionally, the facility did not incorporate a Hazard Vulnerability Analysis and Summary into the assessment, which is required to address potential emergencies and natural disasters. The Administrator admitted that the analysis was part of the facility's disaster plan but was not included in the facility assessment. Both the Administrator and the DON recognized that the current facility assessment did not meet the new requirements and contained numerous incomplete sections.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
The facility failed to accurately complete its Facility Assessment. The assessment did not reflect the skill sets needed for the resident population or list medical equipment in use, including an AED, tracheostomy care and management, a Life Vest, wound vac machines, and glucometer devices. The NHA confirmed the omission during interview.
The facility failed to keep the Facility Assessment accurate by leaving the former Administrator listed on the document even after it was reviewed with QAPI. The current Administrator stated he was not employed at the time of the review and acknowledged he mistakenly did not update the administrative staff. This affected 58 of 58 residents.
Facility Assessment Missing Unit-Based Nursing Staffing Details: The facility failed to complete a thorough facility-wide assessment of nursing staff resources needed for resident care during routine operations and emergencies. The assessment did not identify the specific RN, LPN/LVN, CMA, and CNA staffing levels needed for each unit based on acuity and census, and it lacked staffing levels for each shift and weekends. An Administrative Nurse and Administrative Staff member stated they were not certain the assessment broke down staffing by shift and unit, including weekends.
Failure to Conduct and Document Facility Assessment: The facility did not have evidence of a required Facility Assessment to determine the resources, staffing, and skill sets needed to care for residents during routine operations and emergencies. The NHA and an RN confirmed that no such assessment was available until after the surveyor requested it.
Facility assessment lacked required input from direct care staff and residents. Review of the assessment showed no indication that direct care staff, resident representatives, and/or family members were involved, and the DON confirmed that none were included in the process.
A resident with severe cognitive impairment, a feeding tube, and a recent ischemic MCA stroke s/p hemicraniectomy was admitted after referral review failed to identify the bone flap and helmet requirement. After the resident developed hypotension and was sent to the ER, the DON stated the resident could not return because of acuity and the facility did not accept residents with helmets for that purpose. The DON and Admissions Director stated the resident should not have been accepted because the referral review missed the clinical condition.
Incomplete Facility Assessment Missing Required Care Resources
Penalty
Summary
The facility failed to accurately complete the Facility Assessment. A review of the Facility Assessment dated 7/15/26 found that the template was not completed to show accurate information about the skill sets necessary to provide the level and types of care needed for the resident population, including specific medical equipment currently in use. The medical equipment section did not include an AED, tracheostomy care and management, a Life Vest, wound vac machines, or glucometer devices. During an interview on 8/7/26 at approximately 12:07 p.m., the Nursing Home Administrator confirmed that the facility failed to accurately complete the Facility Assessment.
Facility Assessment Listed Former Administrator
Penalty
Summary
The facility failed to maintain an accurate Facility Assessment that reflected the current administrative staff. The Facility Assessment had been updated and reviewed with the QAPI committee on 3/30/26, but page 1 still listed the former Administrator. During an interview on 7/30/26 at 4:45 PM, the Administrator stated he was not employed by the facility when the Facility Assessment was reviewed and updated on 3/30/26 and acknowledged that he had reviewed the current Facility Assessment but mistakenly did not update the administrative staff. This deficient practice was identified as affecting 58 of 58 residents.
Facility Assessment Missing Unit-Based Nursing Staffing Details
Penalty
Summary
The facility failed to conduct a thorough facility-wide assessment to determine the nursing staff resources necessary to care for residents competently during day-to-day operations and emergencies. Review of the Facility Assessment dated 03/22/2026 showed that it did not identify the specific staffing levels needed for each unit or the number of RN, LPN/LVN, CMA, and CNA staff needed for each unit based on resident acuity and census. The assessment also did not include the staffing levels required for each daily shift or for weekends. During interviews on 07/29/2026, Administrative Nurse D stated that the facility assessment should reflect the total hours for each nursing staff, but could not state for certain whether it broke down each required nursing staff per shift. Administrative Staff A stated the Facility Assessment was reviewed annually and information was included per the new guidelines, but she was not aware that the staffing plan needed to be broken down for each category of nursing staff each shift and for each unit, including weekends. The facility policy dated 08/01/2024 stated the Facility Assessment would address resident population, staff competencies and skill set, physical environment, equipment, services, personnel, contracts, and an all-hazards risk assessment.
Failure to Conduct and Document Facility Assessment
Penalty
Summary
The facility failed to conduct and document a facility-wide assessment to determine what resources were necessary to care for residents competently during day-to-day operations, including nights and weekends, and during emergencies. During interviews with the Nursing Home Administrator on July 21, 2026, July 22, 2026, and July 23, 2026, the surveyor requested the Facility Assessment document, described as an assessment of the resident population that includes evaluation of diseases, conditions, physical or cognitive limitations, acuity, and other pertinent information affecting services the facility must provide. On July 24, 2026, the Nursing Home Administrator and an RN confirmed that the facility had no evidence of a Facility Assessment identifying the education and skill sets necessary for nursing staff providing resident care until after the surveyor requested the document.
Facility Assessment Lacked Required Staff and Resident Input
Penalty
Summary
The facility failed to conduct and document a facility-wide assessment that included active involvement from direct care staff and input from residents. Review of the facility assessment dated April 23, 2026, showed no indication that direct care staff, resident representatives, and/or family members were involved in the assessment process. During an interview on July 24, 2026, the Director of Nursing confirmed that no direct care staff, resident representatives, and/or family members were included in the facility assessment.
Failure to Properly Screen Resident With Hemicraniectomy Before Admission
Penalty
Summary
The facility failed to appropriately pre-screen a resident before admission to determine whether it could meet the resident’s needs and later discharged the resident because it was unable to provide the required care. The resident had an admission MDS with diagnoses including cerebral infarction due to thrombosis of precerebral arteries, hemiplegia following a cerebral infarction on the right dominant side, encephalitis and encephalomyelitis, and a feeding tube. The resident’s BIMS score was 99, indicating severe cognitive impairment. The referral packet from the hospital identified an acute ischemic left MCA stroke status post decompressive hemicraniectomy, and the hospital discharge summary documented acute ischemic MCA stroke status post hemicraniectomy and a left hemicraniectomy. After admission, the resident had low blood pressure and was sent to the ER for evaluation and treatment. Hospital records show the DON called the hospital to state that, due to the patient’s history of craniotomy, the patient could not return to the facility because of acuity. Interviews showed the facility later determined the resident was not appropriate for placement because of the bone flap and helmet used for protection, and the DON stated the facility does not accept residents with helmets for that purpose and does not use physical restraints. The DON stated the facility recognized it should not have accepted the resident, and the FL stated he accepted the resident because the paperwork did not indicate the bone flap and he was unaware the facility could not provide care for that condition. The Admissions Director also stated the resident was not appropriate for placement and that the referral was missed.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release October 8, 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.