Facility-Wide Assessment Lacks Behavioral Health Considerations
Penalty
No penalty information released
The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.
Summary
The facility failed to ensure its facility-wide assessment addressed the behavioral health needs of its resident population as required. Record review showed that 42 residents were identified as having behavioral health needs. However, the facility's most recent facility-wide assessment, last revised in September 2024, did not contain any documented evidence that it addressed the behavioral health needs of the resident population, staff competencies related to those needs, or the facility resources necessary to care for residents with behavioral health needs. This deficiency was identified for three sampled residents reviewed for behavioral health needs. During an interview, the administrator confirmed these findings.