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F0838
F

Failure to Accurately Assess and Document Staffing Needs Due to Shared Staff with Assisted Living

Zumbrota, Minnesota Survey Completed on 05-27-2025

Penalty

No penalty information released
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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 review and update its facility-wide assessment to accurately identify the staffing plan necessary to meet residents' needs during both routine operations and emergencies. Documentation and interviews revealed that overnight staff assigned to the nursing home were also providing services at the assisted living facility, a practice not reflected in the facility's assessment or staffing plan. The staffing plan listed the number of licensed nurses, nursing assistants (NAs), and trained medication aides (TMAs) required for each shift but did not account for the time these staff spent working in the assisted living facility. As a result, the actual number of staff available to care for residents in the nursing home was less than what was documented in the assessment. The administrator and DON confirmed that staff had been providing care at the assisted living facility during their scheduled shifts at the nursing home, and that this practice had been ongoing for some time. The administrator acknowledged that the facility assessment was not accurate, as it included staff hours spent in the assisted living facility as part of the nursing home's staffing hours. The facility assessment policy was requested but not provided. No information was given regarding specific residents affected or their medical conditions at the time of the deficiency.

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