Failure to Update Facility-Wide Assessment
Penalty
Summary
The facility failed to review and update its facility-wide assessment to determine the necessary resources for competent resident care during both routine operations and emergencies. The facility's policy required that the assessment be conducted, documented, and reviewed at least annually, with the Administrator responsible for ensuring its completion. The last documented assessment was dated June 2023, with a review date in July 2023, and indicated a capacity for 226 residents, while the actual census averaged 115 residents at that time. Despite policy stating monthly reviews, there was no evidence of updates or reviews since 2023. Interviews revealed that the Director of Nursing had no involvement with the facility assessment, confirming it was solely the Administrator's responsibility. The current Administrator, who began in March 2025, acknowledged that the assessment had not been updated since 2023 and stated she was in the process of updating it, pending feedback from residents and their representatives. As a result, the facility failed to maintain an up-to-date assessment, potentially affecting all 131 residents.