Failure to Conduct Comprehensive Facility-Wide Resource Assessment
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 provided by administrative staff was updated to reflect recent CMS staffing requirements and identified required staffing needs per day, but did not specify staffing needs by shift for weekends or for the specialized Memory Care Unit. Review of the facility's Payroll Based Journal (PBJ) data over a one-year period revealed excessively low weekend staffing for all four quarters. The facility's own policy required assessment of resources for evenings, nights, and weekends, but the documentation did not meet these requirements. This deficiency affected all 74 residents in the facility.