Incomplete Facility Assessment for Resource and Staffing Needs
Penalty
Summary
The facility failed to complete a comprehensive facility-wide assessment to determine the necessary resources for competent resident care during both routine operations and emergencies. Record reviews revealed that the facility assessment, dated 10/25/2024 and reviewed by the QAA Committee, contained incomplete sentences and blanks, particularly in sections addressing staffing patterns and goals. The assessment did not fully articulate how staffing levels and assignments were determined or maintained, and some statements were left unfinished, such as the goal for actual PPD (per patient day) staffing. The documentation also lacked specific details on how specialized rehabilitation and behavioral health services staffing were evaluated and ensured to be adequate. During a staff interview, the Administrator acknowledged that the facility assessment was considered complete despite the presence of incomplete information and missing data. This deficient practice was identified as having the potential to affect all 214 residents in the facility, as the assessment is a critical tool for ensuring that staffing and resources are sufficient to meet residents' needs at all times, including nights, weekends, and emergencies.