Deficient Facility Assessment Lacks Required Involvement and Staffing Plans
Summary
The facility failed to ensure its Facility Assessment was developed in accordance with federal requirements. Specifically, the assessment did not demonstrate the active involvement of required individuals, including direct care staff, direct care representatives, residents, resident representatives, and family members. This omission was confirmed during an interview with the Administrator, who acknowledged that these groups were not actively involved in the development of the Facility Assessment. Additionally, the Facility Assessment did not address the resources necessary to care for residents during weekends, nor did it include a plan to maximize recruitment and retention of direct care staff. The assessment also lacked a contingency plan for staffing needs in situations that do not require activation of the facility's emergency plan. These deficiencies were identified through a review of the facility's documentation and were verified by the Administrator. The Administrator further confirmed that the Facility Assessment had not been updated to reflect the latest CMS guidance, which requires these elements to be included. The lack of comprehensive identification and addressing of the resident population's needs and available resources had the potential to result in unmet care needs for residents.
Plan Of Correction
How corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice. On 6/24/25, administrator completed the most current version of the Facility Assessment. The assessment was brought to the QA committee for discussion and approval on 6/25/25. How the facility will identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken. All residents have potential to be affected by the deficient practice. The administrator will continue to gather feedback from emergency drills, monthly safety meetings, monthly all-staff meetings, and monthly QA for feedback on communication protocol and any necessary changes to Facility assessment and Emergency Operations Plan in the event of an emergency. What measures will be put into place or what systemic changes the facility will make to ensure that the deficient practice does not recur. Administrator will verify the most recent version of the facility assessment prior to creating the Facility Assessment for 2026 and upcoming years. How the facility plans to monitor its performance to make sure that solutions are sustained. Facility Assessment will be discussed at the monthly QA meeting for feedback from floor staff and department heads to review findings from monthly safety committee/all-staff meetings and learnings from disaster/fire/emergency drills. Date of compliance: 6/25/25
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
Failure to Update Facility Assessment Annually: The facility failed to conduct and document an annual facility-wide assessment to determine resources needed to care for residents competently. Record review showed the Facility Assessment had not been updated since January 2025. The AIT and Interim ADM both stated they had not reviewed the assessment after assuming their roles and acknowledged it should be reviewed and updated annually or when significant changes occurred.
Facility Assessment Missing Staffing and Resource Details: The facility failed to complete a Facility Assessment with the required details on staffing decisions, specific staffing needs by unit and shift, staff competencies, and a plan to maximize recruitment and retention of direct care staff. The assessment also lacked evidence of the resources needed for competent resident care during routine operations and emergencies. The ADMN stated she used the prior administrator’s assessment as a template and was unaware these items needed to be included; the facility also had no policy for the Facility Assessment.
Facility Assessment Not Updated for Lack of RT Contract: The facility failed to update its Facility Assessment after it no longer had an active RT contract. The assessment still listed RT as a needed resource, while the Admin confirmed there was no contracted RT company in place and acknowledged the assessment should be updated annually and as needed.
Incomplete Facility Assessment With Blank Nurse Staffing Section: The facility failed to complete and document a facility-wide assessment used to staff the facility, leaving the nurse staffing section blank. The Administrator stated she had not updated the assessment based on census, and the RCN stated residents were at risk of not receiving timely care. The facility also stated it did not have a facility assessment policy it followed.
The facility failed to complete and document a comprehensive facility-wide assessment for resident care needs during routine operations and emergencies. The 2025 Facility Assessment was signed by former leadership, referenced a missing Staffing and Personnel Worksheet, listed prior admin and DON staff, and contained multiple sections stating no records were found. The facility also could not provide evidence of a plan to maximize recruitment and retention of direct care staff, and the DON acknowledged the assessment did not accurately reflect staffing patterns.
Facility Assessment Not Reviewed Annually: The facility failed to review and update its Facility Assessment annually. The ADON confirmed the assessment had not been updated or reviewed since 2023, despite 77 residents in the facility, and stated there was no policy on Facility Assessment. The Administrator was unavailable for interview initially and later said he thought the assessment had been reviewed last year.
Failure to Update Facility Assessment Annually
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment for the past year to determine what resources were necessary to care for residents competently during day-to-day operations and to review and update the assessment at least annually for 1 of 1 facility reviewed. Record review showed the Facility Assessment had not been updated since January 2025. A facility policy titled Facility Assessment, revised October 2018, stated that a facility assessment is conducted annually to determine and update the facility’s capacity to meet resident needs and competently care for residents during day-to-day operations, and that the assessment is reviewed and updated annually and as needed. During an interview on 06/30/26 at 1:59 PM, the AIT stated she had served in that role since July 2025 and had not reviewed the Facility Assessment since assuming the position because she had not had time. She stated it had been updated before the previous survey and acknowledged it was her responsibility along with the ADM to update the Facility Assessment and that it should be reviewed and updated annually or whenever significant changes occurred. She stated the only changes since the last update had been administrative leadership changes and said she would update the assessment that day with assistance from the Interim ADM. During an interview on 06/30/26 at 2:55 PM, the Interim ADM stated she had been employed at the facility since February 2026, had not reviewed the Facility Assessment upon assuming her position, and was unsure when it had last been updated. She stated she believed it was her responsibility to update the assessment annually or when changes occurred and thought it had already been updated during 2026.
Facility Assessment Missing Staffing and Resource Details
Penalty
Summary
The facility failed to conduct and document a facility-wide assessment that identified the resources needed to care for residents competently during daily operations and emergencies. The Facility Assessment, dated 01/05/2026, contained no evidence of the resources needed to provide competent resident support and care, staff training and education, staff competencies, staff assignment needs, or a plan to maximize recruitment and retention of direct care staff. The assessment was reviewed by QAPI on 01/23/2026, and no governing body member was present. Record review of the Resident Matrix, dated 06/29/2026, showed a census of 59 residents, including 17 residents with falls, 3 residents with pressure ulcers, 3 residents with infections, and 1 resident who used an enteral tube for nutrition and medication administration. During interview, the ADMN stated she was responsible for completing the Facility Assessment and had used the prior Administrator’s assessment as a template. She stated she was unaware the assessment needed to include staffing decisions, how staffing needs were determined, or how the facility planned to retain staff. She also stated the facility did not have a policy regarding the Facility Assessment.
Facility Assessment Not Updated for Lack of RT Contract
Penalty
Summary
The facility failed to implement its policy and procedure titled Facility Assessment when it did not update the assessment after it no longer had a contracted Respiratory Therapy (RT) company. The facility assessment, dated 1/27/2026, still indicated RT as a resource needed by the facility, even though the Administrator stated during interview that there was no active RT contract in place and that it was not appropriate to include RT in the assessment without one. During concurrent interview and record review on 6/26/2026 at 1:40 p.m., the Administrator reviewed the Facility Assessment and confirmed the facility did not have an active contracted RT company. The facility’s policy titled Facility Assessment, dated 1/2026, stated the assessment should be reviewed and updated as necessary and at least annually whenever there is, or the facility plans for, any change that would require a substantial modification to any part of the assessment.
Incomplete Facility Assessment With Blank Nurse Staffing Section
Penalty
Summary
The facility failed to conduct and document a facility-wide assessment to determine what resources were necessary to care for residents competently during day-to-day operations and emergencies. Record review of the facility assessment dated [DATE] showed that the assessment was incomplete and was being used to staff the facility, with the nurse staffing section left blank. The blank section was supposed to identify the number of licensed nurses and certified nurse aides needed on the day shift and night shift based on the facility census and acuity of care needs. During an interview on 06/25/2026 at 12:30 p.m., the Administrator stated she had been working at the facility for 2 weeks and had not updated the facility assessment. She stated it was the Administrator’s responsibility to complete and update the assessment according to census and said she had not had time to update it, although she had a prior copy dated 12/31/2025. She acknowledged that the prior assessment was incomplete with the nurse staffing portion left blank. During an interview on 06/25/2026 at 1:30 p.m., the RCN stated that a completed facility assessment was provided after surveyor intervention, expected the Administrator to keep it updated in accordance with census, and stated residents were at risk of not receiving timely care. The RCN also stated the facility did not have a facility assessment policy that they follow.
Facility Assessment Not Updated to Reflect Staffing Needs
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment to determine what resources were necessary to care for residents competently during day-to-day operations, including nights and weekends, and during emergencies. Review of a community-reported complaint alleged a severe and persistent staffing shortage at the facility. Review of the 2025 Facility Assessment showed it was signed by the former administrator and former DNS on 3/30/2026, and it referenced a Staffing and Personnel Worksheet that was not found in the attachments. Multiple supporting document sections stated, "No records were found." The assessment also listed previous employees as the administrator and DNS rather than the current administrator and DNS. The facility also failed to provide evidence of a plan to maximize recruitment and retention of direct care staff. During interview, the DNS acknowledged that the Facility Assessment did not accurately reflect the staffing patterns of the facility and could not provide evidence of a recruitment and retention plan for direct care staff.
Facility Assessment Not Reviewed Annually
Penalty
Summary
The facility failed to conduct and document a facility-wide assessment to determine the resources needed to care for residents competently during day-to-day operations and emergencies because the Facility Assessment was not reviewed or updated annually. The facility census dated 6/9/26 showed 77 residents residing in the facility, and the Facility Assessment had last been revised and updated on 7/31/23. On 6/10/26 at 2:00 PM, the ADON stated the Administrator was responsible for updating and reviewing the Facility Assessment annually and confirmed it had not been updated or reviewed since 2023. The ADON also stated the facility did not have a policy on Facility Assessment. The Administrator was not available for interview on 6/10/26 or 6/11/26, and on 6/15/26 at 12:00 PM, the Administrator said he thought the Facility Assessment was reviewed last year.
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