Lack of Annual Review and Stakeholder Involvement in Facility Assessment
Summary
The facility staff failed to provide credible evidence that the facility assessment was reviewed at least annually and did not ensure the involvement of appropriate participants in the assessment process. This deficiency was identified during a review conducted on January 27, 2025, which revealed a lack of documentation indicating when the facility assessment was last reviewed and who participated in the process. The data within the assessment included outdated Quality Measure reports from December 2018 to February 2019 and more recent reports from August 2023 to October 2023. However, there was no evidence of active involvement from direct care staff, residents, resident representatives, or family members in the development or review of the facility assessment. The facility's Administrator and Regional Vice President of Operations were unable to provide further information regarding the review process or the participants involved. They assumed the assessment was discussed around July 2024, when it was uploaded online, but lacked evidence to support this claim. A meeting with the facility administrator, Director of Nursing, and corporate management staff confirmed the absence of credible evidence of involvement from key stakeholders in the assessment process. The facility's policy on facility assessment outlined the need for annual review and involvement of the governing body, but no additional information was provided to demonstrate compliance with these requirements.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release July 29, 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.