Incomplete Facility Assessment Documentation
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to accurately complete and document its facility-wide assessment, which is necessary to determine the resources required to care for residents during both routine operations and emergencies. Record review showed that the assessment, dated and signed by the Administrator, Regional Director of Operations, and DON, was reviewed at the Quality Assurance Agency meeting in January 2025 but did not include the facility's capacity or average daily census. During an interview, the Administrator confirmed that the assessment provided was missing this critical information and acknowledged that the version submitted was not correct. A second, unsigned version was later produced, which did not match the original assessment.