Failure to Conduct Comprehensive Facility-Wide Assessment for Staffing Needs
Penalty
Summary
The facility failed to conduct a thorough facility-wide assessment to determine the resources necessary to care for residents competently during both day-to-day operations and emergencies. The assessment, last updated on 01/30/25, identified required staffing needs per day but did not specify staffing needs by shift for weekends. Review of the facility's Payroll Based Journaling (PBJ) Staffing Data Report for the previous year showed excessively low weekend staffing in all four quarters. The administrator confirmed that nursing hours were set by the corporate office and that the assessment did not differentiate between weekday and weekend staffing, despite weekends being staffed differently due to increased staff presence on weekdays. The facility's policy required a documented assessment of resources needed for resident care during both regular operations and emergencies, but this was not fully implemented.