Deficiency in Facility-Wide Assessment for Smoking and Cultural Needs
Summary
The facility failed to conduct a comprehensive facility-wide assessment that adequately addressed the needs of residents who smoke and the cultural needs of the Asian American population. The deficiency was identified through observations, interviews, and document reviews. The Licensed Nursing Home Administrator (LNHA) provided smoking hours and a list of residents who smoke, but the facility's smoking policy was insufficiently documented as it was only represented by a 'Smoking Rules and Agreement' document. Staff interviews revealed a lack of clarity and consistency in the smoking process, with discrepancies in who was responsible for holding residents' cigarettes and lighters. Additionally, there was confusion about the existence and location of a list of residents requiring smoking aprons, indicating a lack of staff knowledge and a formalized smoking policy. The facility also failed to address the cultural needs of its Asian American residents. A family member of a resident expressed concern about the lack of a daily Korean newspaper, which was supposed to be provided. Although the facility had menus and activity calendars in Chinese, there was no clear process or responsibility for ensuring the delivery of culturally appropriate materials, such as the Korean newspaper. The Activities Director was aware of the resident's needs but was unsure who was responsible for providing the newspaper. The facility assessment tool did not adequately address these cultural needs, highlighting a gap in the facility's ability to provide culturally competent care.
Plan Of Correction
Rose Mountain Care Center Facility ID: 3145384 Survey completion date: 12-12-2024 **F838 SS-E Facility Assessment** **Element One:** All staff were immediately educated on the smoking policy and process. A newspaper was immediately ordered for the resident. The facility assessment was updated ensuring all resources necessary for the care of the residents are documented. **Element Two:** All residents who smoke and the residents from the Asian population had the potential to be affected by the deficient practice. **Element Three:** All staff were educated regarding the facility's smoking policy and process. The activity staff and admissions staff were educated to inform the administrator if there are any delays in the newspaper being delivered. The facility Administrator was educated by the Regional Administrator on the facility assessment requirements and ensuring all resources necessary for the care of the residents are documented. The residents were explained the importance of smoking safety and following the rules. They were educated about not holding their cigarettes and lighters as well as the designated smoking times. The residents were also educated on the facility's smoking policy and process. **Element Four:** The Administrator/designee will continue to monitor the smoking program to ensure safety. The Administrator will review the facility assessment monthly for 3 months, then quarterly, as well as updating it on an as-needed basis. Results will be reported to the QAPI team for review. Completion Date: 12-25-2024
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Facility Assessment failed to identify the staffing resources needed from 11:00 P.M. to 7:00 A.M. Review showed the assessment addressed staffing needs only from 7:00 A.M. to 11:00 P.M., and the Administrator confirmed the overnight gap during interview. The issue was found during a complaint investigation and had the potential to affect all 64 residents.
Facility Assessment Missing Staffing and Contingency Planning Details: The facility failed to include specific staffing needs per unit and shift, a plan to support recruitment and retention of direct care staff, and a contingency plan for events that could affect resident care without activating the emergency plan. The Facility Assessment also lacked a total calculation of hours worked per shift and a list of personnel in house to meet resident needs, and the DON/Administrator confirmed these omissions during interview.
Facility Assessment Did Not Reflect Locked Memory Care Unit or Resident Needs. The facility failed to update its Facility Assessment after opening a locked memory care unit on B-Wing for residents with dementia or wandering tendencies. The assessment did not identify the unit, the 34 residents living there, or the services, staffing, competencies, and resources needed to meet resident needs, including resident acuity, cognitive impairment, and behavioral or physical health needs. The NHA confirmed the assessment was incomplete.
Facility Assessment Lacked Specific Staffing Determinations: The facility failed to complete a comprehensive, facility-specific assessment identifying the staffing resources needed to care for residents based on census and acuity. The assessment listed a high-need resident population, including residents needing ADL help, maximal assistance, psychiatric/mood care, neurological care, anticoagulation monitoring, and Memory Care supervision, but only used general statements about staffing based on acuity and hours per patient day. It did not specify required numbers or ratios of CNAs, RNs/LPNs, management, or ancillary staff, nor did it document staffing needs by shift, unit, or changing resident needs.
The facility failed to ensure its facility assessment identified specific staffing needs for each resident unit for a census of 72 residents. The assessment listed overall direct care staffing for day, evening, and night shifts, but it did not break down staffing needs by resident unit. An HR director confirmed that the assessment did not include unit-specific staffing.
Facility Assessment was incomplete because it did not include resident acuity, diseases, conditions, physical or behavioral health needs, cognitive status, or special treatments and conditions. It also did not list the number of nurse aides needed for the day, evening, and night shifts. The Administrator stated the acuity information and CNA staffing numbers had been overlooked and that the assessment was meant to guide staffing based on resident need.
Facility Assessment Did Not Address Overnight Staffing Needs
Penalty
Summary
The facility failed to ensure a comprehensive Facility Assessment was developed to identify the staffing resources needed to provide care for residents competently during day-to-day operations and emergencies. Review of the Facility Assessment, updated 01/25/26, showed that it addressed staffing needs from 7:00 A.M. until 11:00 P.M., but it did not identify the staffing resources needed from 11:00 P.M. until 7:00 A.M. The facility census was 64 residents, and the deficiency had the potential to affect all 64 residents. During an interview on 05/07/26 at 2:40 P.M., the Administrator verified that the Facility Assessment identified staffing resources for 7:00 A.M. until 11:00 P.M. but did not identify staffing resources for 11:00 P.M. until 7:00 A.M. This was an incidental finding discovered during the complaint investigation.
Facility Assessment Missing Staffing and Contingency Planning Details
Penalty
Summary
The facility failed to ensure that its facility assessment included information related to staffing levels needed for specific shifts, a plan to maximize recruitment and retention of direct care staff, and a contingency plan for events that do not require activation of the facility emergency plan but still have the potential to affect resident care. The report states that the facility census was 62 residents, and the deficiency had the potential to affect all residents who resided in the facility. A record review of the facility’s undated Facility Assessment policy showed that the assessment was intended to address resident population, staff competencies and skill sets, physical environment, equipment and services, cultural, ethnic, and religious factors, and facility resources, and to inform staffing decisions, including specific staffing needs per unit and each shift, recruitment and retention planning, and contingency planning for non-emergency events. However, the Facility Assessment dated [DATE] contained no information related to specific staffing needs per unit and each shift, no total calculation of hours worked per shift, no plan for staff development or retention, and no contingency plan for events that could affect residents without activating the emergency plan. During interview on 05/21/2026 at 7:20 AM, the Administrator confirmed that the assessment did not include specific staffing needs per unit per shift, did not list specific personnel in house to meet resident needs, did not cover staffing levels with numbers of staff needed for each shift, and did not include recruitment, retention, or contingency planning.
Facility Assessment Did Not Reflect Locked Memory Care Unit or Resident Needs
Penalty
Summary
The facility failed to conduct and update a facility-wide assessment to determine the resources necessary to care for residents competently during day-to-day operations and emergencies. Review of the current floor plan showed the B-Wing residential section outlined in red, and the Nursing Home Administrator stated this indicated a locked unit. The facility had created and opened a locked memory care unit for residents with dementia or wandering tendencies on November 4, 2025. Observation of the B-Wing from May 19, 2026, through May 21, 2026, showed the unit doors were locked, required a security code for entry and exit, and sounded an audible alarm when opened after the code was entered. The facility’s matrix identified 34 residents residing on the B-Wing. Review of the Facility Assessment, last reviewed on March 3, 2026, showed it did not identify the locked memory care unit or the specific services, staffing, and resources needed to meet the individual and collective needs of the residents on that unit. The assessment also did not include comprehensive data about the current resident population, including disease types, conditions, physical and behavioral health needs, cognitive impairments, and overall acuity. It further failed to identify how increased resident acuity affected staffing needs, workload, supervision, and the time required to provide basic care, and it did not evaluate the overall number of staff or the competencies and skill sets needed to ensure qualified staff were available to meet resident needs. During interview, the NHA confirmed the Facility Assessment did not contain all required information related to the facility’s current resident population, services, and staffing resources.
Facility Assessment Lacked Specific Staffing Determinations
Penalty
Summary
The facility failed to conduct and document a comprehensive, facility-specific assessment that identified the staffing resources needed to care for residents competently during routine operations and emergencies. The assessment reviewed on 5/18/26 showed an average resident population of 185 admissions/stays, including 106 ongoing stays and 134 long-stay residents, with significant care needs including 99 residents requiring ADL assistance, 89 residents needing maximal assistance or help from two or more staff, 125 residents with psychiatric/mood diagnoses, 102 residents with neurological conditions, 166 residents requiring anticoagulation monitoring, and residents on a designated Memory Care Unit requiring specialized dementia care and supervision. Section II of the Facility Assessment contained only general statements that staffing was based on resident acuity and an hours-per-patient-day basis, and that staff assignments were designated individually. The assessment did not specify the actual staffing resources needed to meet resident needs, including the number and ratio of direct care staff, licensed nurses, management personnel, or ancillary staff for the facility’s census and acuity. The Sufficiency Analysis categories were documented only as "Evaluated" for multiple domains, including cognitive impairment/dementia, wandering and elopement, and behavioral health needs, without measurable staffing determinations such as minimum nursing staff per shift, CNA-to-resident ratios, licensed nurse-to-resident ratios, Memory Care Unit staffing needs, staffing adjustments based on acuity or census changes, or documentation showing how staffing sufficiency was analyzed and determined. The Administrator stated the assessment had been created, updated, and revised by corporate staff off-site and acknowledged it was not sufficiently detailed or specific to identify the building’s staffing needs.
Facility Assessment Lacked Unit-Specific Staffing Needs
Penalty
Summary
The facility failed to ensure that its facility assessment included specific staffing needs for each resident unit for a census of 72 residents. Review of the facility assessment on 5/20/26 showed a staffing plan stating that direct care staff would include 3 licensed nurses and 7 nurse aides on day shift, 3 licensed nurses and 7 nurse aides on evening shift, and 2 licensed nurses and 4 nurse aides on night shift, with staffing intended to fluctuate based on acuity and staff competency. Further review found that the assessment did not identify staffing needs by resident unit. During an interview on 5/21/26 at approximately 10:23 a.m., Staff F, the Director of Human Resources, confirmed that the facility assessment did not break down staffing for each resident unit.
Facility Assessment Missing Resident Acuity and Staffing Details
Penalty
Summary
The facility failed to ensure its Facility Assessment was reviewed and updated as necessary, and at least annually, to include the resident population, diseases, conditions, physical and behavioral health needs, cognitive status, acuity of the resident population, and other pertinent information for 1 of 1 facility. Record review of the Facility Assessment dated [DATE] showed that the Resident Acuity section did not outline the acuity of the resident population, and the Special Treatments and Conditions section did not include information concerning the resident population. The assessment also did not identify the number of nurse aides needed for the day, evening, and night shifts in the Staff Planning section under Facility Resources Needed to Provide Competent Support and Care for the Resident Population Every Day and During Emergencies. During interview, the Administrator stated he must have overlooked adding the resident acuity information and the number of nurse aides needed to provide care. He stated the Facility Assessment was intended to summarize the types of residents cared for and provide a base for how many staff were needed for different levels of acuity, and that it was a guide for staffing nurses and CNAs on each shift.
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