Facility Assessment Lacked Accuracy and Current Resource Information
Penalty
Summary
The facility failed to maintain an up-to-date and accurate facility-wide assessment, as required, to determine the necessary resources for competent resident care during both routine operations and emergencies. Record review revealed that the assessment did not include translation services for three non-English speaking residents, despite listing their language needs. Additionally, the assessment contained inaccurate information regarding a staffing waiver for CNA hours, which the facility did not actually possess. The vendor list was also outdated, listing a contact who no longer worked at a medical gas vendor and omitting the facility's contracted physician group. Interviews with the Administrator confirmed these deficiencies, including the absence of translation services in the assessment, outdated vendor contact information, missing contracted physician information, and incorrect details about the staffing waiver. The facility's assessment, dated 2025, was found to be incomplete and not reflective of the current resources and needs of the resident population, potentially impacting the facility's ability to provide appropriate care at all times.