Inadequate Facility Assessment and Activities Program
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment to determine the necessary resources for resident care during both routine operations and emergencies. The assessment provided was not tailored to the specific needs of the residents, lacking detailed information on nurse staffing requirements, including staffing levels, use of agency staff, recruitment and retention plans, and emergency contingency plans. The facility had a census of 90 residents, with 18 under the age of 60 and 80-85 with mental health diagnoses, yet the assessment did not address the specific activity needs of these populations. Additionally, the facility's activities program was inadequate, failing to meet the cognitive, functional, and recreational needs of its residents, particularly the younger residents and those with mental health diagnoses. Residents expressed dissatisfaction with the activities program, noting that Bingo prizes were used items and there was no designated activity budget. The facility relied heavily on agency staff for over 60% of its nursing needs and employed less than half of its required nursing staff, which was confirmed by the Nursing Home Administrator. These deficiencies have the potential to negatively affect the quality of care and quality of life for all residents.
Plan Of Correction
1. Ridgeview Healthcare and Rehabilitation Center's Facility Assessment was updated to include the identified areas as outlined in the statement of deficiencies from the annual survey ending December 20, 2024. 2. Regional Administrator educated NHA & IDT team on importance of maintaining the Facility Assessment accurately to reflect current environment of the facility. 3. Updates to Ridgeview Healthcare and Rehabilitation Center's Facility Assessment will be completed upon changes within the organization or at least annually. 4. Ridgeview Healthcare and Rehabilitation Center's Facility Assessment will be reviewed monthly at the QA Committee meeting for three months and at least annually thereafter.