Inaccurate Facility Assessment Documentation
Penalty
Summary
A facility-wide assessment failed to accurately reflect the services provided, as discovered during a recertification survey. The assessment incorrectly documented an average of 10 resident admissions during the weekday and did not include the facility's capacity to admit residents with infectious diseases such as COVID-19, MRSA, or Clostridium Difficile. Additionally, the section regarding care for residents with conditions not listed was incomplete, and while the assessment stated the facility could care for residents with a tracheostomy, there were no current residents with this condition. The assessment also omitted showers as a form of assistance provided for activities of daily living. During interviews, the DON acknowledged that it had been some time since nurses participated in a skills lab, and there were no competencies to verify staff training for tracheostomy or gastrostomy tube care. The Administrator confirmed that the reported average of 10 admissions per week was an error.