Incomplete Facility Assessment Documentation
Penalty
Summary
The facility failed to provide a complete and detailed facility-wide assessment as required. Review of the Enhanced Facility Assessment, last updated by the Administrator, showed that it did not identify all personnel involved in the writing and approval process, did not provide an accurate average census, and did not accurately report the average number of residents admitted and discharged daily. Additionally, the assessment lacked information on common diagnoses admitted to the facility, the types of services or care offered, and details regarding staffing levels for each shift. During an interview, the Administrator acknowledged and agreed with these discrepancies. This deficiency had the potential to affect all 81 residents residing in the facility.